Inspiring Healthy Adolescent Choices: A Rationale for and Guide to Strength Promotion in Primary Care

Article Outline

• Abstract
• Addressing Risk
• Addressing Health
• Applying these Concepts in an Office Setting
  • Setting the Stage
  • Interaction
  • Risk and Strength Assessment
  • Encouragement
  • Intervention
  • Parents
• Conclusion
• Acknowledgments
• Appendix
  • Additional Resources
    • Online
    • Print
• References
• Copyright

Abstract 

The social, emotional, and biological health of adolescents requires their development as autonomous beings who make responsible decisions about their own health. Clinicians can assist in this development by adopting a strength-based approach to adolescent health care, which applies concepts from positive youth development to the medical office setting.

Keywords: Positive youth development, Adolescent, Risk factors, Health promotion, Preventive health services

It is widely accepted that the main threats to the health of adolescents today are preventable risk behaviors [1], [2]. These include inadequate physical activity, inadequate nutrition, sexual behavior that may lead to unintended pregnancy or infection, substance use and abuse, and behaviors that contribute to unintentional injuries and violence [3], [4]. Assessment for social and behavioral risks has become part of the adolescent care guidelines for all health visits [5], [6], and prevention has become a “core value” for pediatric research and education [7]. However, health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [8]; an adolescent who is free from risks is not necessarily “healthy.” As sociologist and founder of the Forum for Youth Investment Karen Pittman has noted, “a child that is problem-free isn’t necessarily fully prepared for adulthood” [9].

Findings from successful community programs for adolescents and theoretical reviews endorsed pairing risk prevention with the promotion of positive youth development [10], [11], [12], [13], [14], [15]. Although prevention efforts seek to dissuade youth from risky behaviors, positive youth development orients youth toward actively seeking out and acquiring the personal, environmental, and social assets that are the “building blocks” for future success. These assets enable healthy and successful transition from childhood, through adolescence, and into adulthood [11], and they are correlated with psychosocial thriving, physical health, and lower likelihood of engaging in negative or risky behaviors during the adolescent years [13], [14].

Within the health care practice setting, prevention efforts typically consist of conducting risk assessments and offering anticipatory guidance. The purpose of this article is to describe a “strengths approach” that enhances office interactions with the knowledge and best practices from the field of positive youth development. The social, emotional, and biological health of adolescents requires their development as autonomous beings who make responsible decisions about their own health. Accordingly, the goals of a strength-based approach are to 1) raise adolescents’ awareness of their developing strengths and the role they can play in their own health and well-being and 2) motivate and assist adolescents in taking on this responsibility. This approach is consistent with the Bright Futures guidelines for health supervision [5] and has been called for by the World Health Organization [16], as well as Bell and Ginsburg [17], [18].

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Addressing Risk 

As a child enters adolescence, practitioners need to shift away from anticipatory guidance directed to parents and move toward risk-reduction and prevention education aimed directly at the adolescent. Rates of risk behavior screening and counseling remain lower than recommended, however, due in part to time constraints, inadequate reimbursement, and limited ancillary support [19], [20]. In addition, risk assessment and counseling can be a difficult task [21]. Adolescents may resist discussing such inherently sensitive subjects as substance use, relationships with peers, and sexuality. If done incorrectly, risk discussions can damage or ruin relationships with the patient and family; in particular, lecturing or one-way communication by the practitioner is rarely successful [22], [23], [24], [25]. The DARE program is one famous example of the ineffectiveness of didactic “Just Say No” messages [25].

To be successful, risk interventions must engage adolescents’ emerging cognitive abilities and accommodate their developmental needs. It should be acknowledged, for example, that risk taking is the adolescents’ way of learning about their environment [26]. As Matt Morton, international youth advocate has noted, “If you don’t give us healthy risks to take, we’ll take unhealthy ones.” [27]. Therefore, along with providing them with information about healthy and unhealthy behaviors, adolescents should be aided in developing skills to manage the difficult situations they will inevitably encounter, and encouraged to seek positive learning opportunities and experiences.

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Addressing Health 

Adolescents are often depicted as potential victims of their environment, but they also have skills, talents, families, peers, and other resources that can help them handle the risks their environment contains. In the fields of adolescent policy and program development, growing awareness of the resources available to adolescents, coupled with mounting evidence of the ineffectiveness of many risk-prevention programs, prompted the exploration of two related concepts: 1) resilience and 2) positive youth development. The concept of resilience emerged from the observation that many children and young adults have good outcomes and successful adulthoods despite serious threats to their development, such as adverse neonatal events, traumatic incidents, poverty, and other harmful conditions [28]. Researchers, program developers, and others sought to identify and promote the protective factors that enable some individuals to prevail over these threats to their development and well-being [29]. One of the key insights from resilience research is that a caring relationship with at least one responsible adult is a significant protective factor [30]. However, resilience, by definition, arises only in the face of adversity. It is, in essence, a learned ability to cope with challenges in the environment. It is difficult to know whether an adolescent who is relatively unchallenged by the environment is developing resilience. Nonetheless, the value of this concept lies in the identification of universal or core assets that could prove helpful to all adolescents [11].

Positive youth development strategies build upon resilience efforts by promoting normal development in all circumstances rather than just adversity, and by recognizing youths’ need for ongoing support as well as challenging opportunities to prompt exploration of their talents, skills, and intelligence [31]. Positive youth development approaches typically focus on the following: 1) development to foster positive outcomes; 2) the whole child (rather than one aspect of a child’s development, environment, or personality); 3) achievements specific to developmental tasks and stages; and 4) interactions with family, school, neighborhood, and societal and cultural contexts [13].

Efforts to determine exactly which experiences, traits, and skills are most essential to resilience and positive development have resulted in several lists of essential developmental assets. Examples are included in Table 1, Table 2. Two general approaches have been used to create such lists. One is to determine the common features promoted or provided by programs that succeed in preventing adverse behaviors. For example, the National Research Council and Institute of Medicine Committee on Community-level Programs for Youth conducted a 2-year study of ongoing strength-promotion efforts and generated a list of “key youth assets that facilitate development” (Institute of Medicine column, Table 1) and a “provisional list of features of daily settings that are important for adolescent development” (Table 3) [41]. The other approach is to identify attributes shared by adolescents who do not engage in risky behaviors. For example, Resnick et al reviewed results from the National Longitudinal Study on Adolescent Health to identify risk and protective factors in four domains of adolescent health and morbidity: emotional health, violence, substance use, and sexuality. They found parent–family connectedness and school connectedness appear to protect against every measured health risk behavior except history of pregnancy [1]. Since 1997, the Search Institute has researched the role of 40 “Developmental Assets” in the long-term health and well-being of young people [37]. Murphey et al studied the influence of the following six assets: 1) grades in school, 2) talking with parents about school, 3) representation in school decision-making, 4) participation in youth programs, 5) volunteering in the community, and 6) feeling valued by the community. The study found the number of assets students possess is inversely related to engagement in each of seven risk behaviors, and directly related to three health-promoting behaviors [46].

Table 1. Strengths checklists oriented toward individual adolescents

Table 2. Frameworks used in research and policy and program development

Table 3. Features of an office setting that supports adolescent strengths

This table is adapted from Programs to Promote Youth Development, National Academies Press, 2007.

For practitioners interested in applying the lessons learned from community-based interventions, the overlap in the various lists in Table 1, Table 2 is reassuring, revealing a core group of assets that can foster healthy development and prevent risky behavior. As Pittman has pointed out, successful prevention programs share a common set of inputs “nearly identical to the list of basic inputs necessary to development and engagement: opportunities for membership, social skill building, participation, clear norms, adult-youth relationships and relevant information and services” [9]. Consensus is still emerging around which assets are most important [47]; but across all socioeconomic and racial/ethnic groups, the presence of assets or strengths is positively linked with increased healthy behaviors and fewer risk behaviors [46], [48], [49].

In sum, assessment and encouragement of strengths and assets is a key strategy for promoting healthy development and reducing risk behaviors. It is endorsed by the US Department of Health and Human Services in the document Toward a Blueprint for Youth: Making Positive Youth Development a National Priority [50], and the Association of Maternal and Child Health Programs adopted positive youth development as one of the guiding principles for policies and programs to maximize the health of adolescents [40]. A medical home office visit system incorporating assessment and promotion of strengths would be supported by the evidence of their important influence on positive adolescent development [51].

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Applying these Concepts in an Office Setting 

Practitioners in social work and psychology have been applying positive youth development concepts to the professional office visit since the early 1990s, if not earlier [30]. In its broadest and most basic sense, adopting a strengths approach in the medical office means modeling respect and kindness toward adolescents and conveying the belief that adolescents have the ability to continue their positive health behaviors or to make a behavior change when needed. An office visit is not just an occasion to assess for and champion the idea of strengths; it is also an opportunity to directly promote strengths in adolescents.

A strength-based approach is being implemented by primary care practitioners (PCPs) in Vermont. A survey of 82 Vermont pediatric and family medicine PCPs found 32.9% currently carry out a “protective factor assessment of youth” [52]. Furthermore, most (60.8%) of the respondents not currently doing these assessments were interested in initiating these screenings with their adolescent patients. This level of awareness and interest in the strengths approach is potentially related to the efforts of the Vermont Youth Health Improvement Initiative (VYHII), which trains PCPs to screen adolescents for risky behaviors, and identify and discuss strengths using Brendtro’s Circle of Courage framework. The Circle of Courage identifies generosity, independence, mastery, and belonging as important qualities for healthy adolescent development [32]. A 2005 study of VYHII participants’ patient charts found that the percentage of youth screened for at least three of the four qualities increased from 34.6% to 65.6% as a result of the training program [53]. One finding of a small qualitative study, however, was providers’ observation that the strength-based approach enhanced communication with youth and helped establish trust. PCPs also reported a high degree of satisfaction with their patient interactions despite a limited amount of time in their visit [54].

Whether practitioners can embrace a strengths approach depends upon effectively addressing the elements discussed in the sections below. Possible challenges to implementation include gaining comfort with the language of strengths promotion; learning to identify strengths in patients who do not seem to meet traditional standards of success; remembering to include strengths even when addressing immediate health risks; and finding enough time, and an appropriate time to ask about or comment on strengths during a visit.

Setting the Stage 

Adolescents should feel not only welcome but also respected within the medical environment. Pratt offers a good description of the many ways medical office staff can unintentionally demean or embarrass adolescents, such as by failing to ensure that adolescents are given privacy when they are dressing or providing samples [21]. Certain features in a practice are more developmentally appropriate and inviting for adolescents, and thus set the stage for a successful visit (Table 3). Practical implications of the list for the medical office include ensuring that conversations cannot be overheard between examination rooms; having age-appropriate decorations, furniture, and reading materials; and posting community volunteer opportunities. One way to improve the friendliness of the office environment is to ask an adolescent or group of adolescents to review the office setting and materials and provide feedback [55].

Interaction 

By building a foundation of rapport and trust during the visit, PCPs indicate respect for the adolescent as a person who is taking increasing responsibility for his or her health and well-being [56]. PCPs and office staff should introduce themselves first to the adolescent, and then to the parents, and direct as many questions as possible directly to the adolescent. Confidentiality should be extended to the adolescent.

Risk and Strength Assessment 

No consensus exists on which particular strengths to promote, nor are there clinical guidelines addressing the development of strengths in adolescence [57]. However, the Guidelines for Adolescent Preventive Services (GAPS) [6] and Bright Futures [5] recommend PCPs ask patients and families about what is going well for the patient and family. This can be done by asking one or two of the following questions: 1) How do you stay healthy? 2) What are you good at? 3) What do you do to help others? 4) Who are the important adults in your life? 4) What are your responsibilities at home? At school? 5) What do you and your friends like to do together? On the weekends? After school? 6) If I were an employer, what are all the things that would make me want to hire you? These questions can elicit information about habits, qualities, values, and skills the patient is developing, and family and community resources supporting the patient in his or her development. Assessment findings such as activities, strengths developed or absent, and challenges the adolescent is facing, can be recorded in the medical record. Reviewing these with the patient at subsequent visits will help reveal any changes and can prompt the PCP to offer praise and demonstrate interest.

Practices participating in the VYHII have been using a “6 + 4” reminder sticker to facilitate the adoption of this approach. The sticker, illustrated in Figure 1, is attached to patient charts and reminds PCPs to ask about and track the six CDC risk behaviors, plus generosity, independence, mastery and belonging, the four assets identified by Brendtro et al [32]. Some VYHII clinicians also hang a “Circle of Courage” poster illustrating these strengths in the exam room, and refer to it during conversations with patients. They can say, for example, “This poster includes the essential qualities for healthy development. Tell me some things you are getting good at.” Other concise strength assessment frameworks suitable for use in an office setting include the READY mnemonic [34], Ryan and Deci’s Autonomy, Relatedness, and Competence (which can be remembered as “ARC”) [38], and the “5 Cs,” which are Contribution, Confidence, Competence, Connection, and Character [9]. These are listed in Table 1, Table 2.

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• Figure 1. 

  Vermont Child Health Improvement Program (VCHIP) reminder sticker. Sticker is attached to patient charts to remind primary care practitioners to track a set of six risk behaviors and four wellness-promoting assets during patient screening visits.

In an already busy office visit, it may seem onerous to add even one or two additional questions. Risk assessment questions that may already be in use can also help assess the presence of strengths. For example, rather than skipping over replies on an office intake form where “there doesn’t seem to be a problem,” PCPs can take a moment to congratulate the youth these positive behaviors. Similarly, negative replies to verbal questions about risky behavior are an opportunity to point out strengths. When asked, “Do you smoke cigarettes?” a reply of “No, and I’m trying to get my parents to quit,” is an opportunity to note the patient’s growing independence. The HEEADSSS Psychosocial Interview for Adolescents [58] often recommended for identifying risky behaviors, can also reveal information that may point to the presence of strengths. Typical HEEADSSS questions include “What do you do for fun?” and “Do you or your friends ever use drugs?” In response, a patient may answer that she has a close group of friends or has pledged to abstain from using drugs, and these can be indicators of important strengths. Table 4 provides additional examples of how answers to HEEADSSS-related questions can help reveal strengths.

Table 4. Using HEEADSSS with a strengths approach

Adapted from Goldenring JM, Rosen DS. Getting into adolescent heads: An essential update. Contemporary Pediatrics, 2007.

Recognizing an adolescent’s strengths can sometimes be challenging, especially if the clinician does not know the adolescent well or is not aware of the family’s cultural or socioeconomic background. Table 5 illustrates how some statements that appear at first glance to indicate only negative or risky behavior, might also indicate the presence of a strength or asset. A clinician may, for example, appropriately express concern for an adolescent who has few friends and spends most of her time caring for younger siblings. However, this information is also an opportunity to praise the adolescent for demonstrating generosity and for (potentially) having a close relationship with her siblings. Contextual, historical, and/or cultural factors will likely be at play in both the PCP’s and adolescent’s views. Clinicians can be aware of their own biases and can ask questions to understand the context of an adolescent’s activities and decisions. Consider for example, that while many youth development programs recommend young people have strong relationships with adults, some cultures will not allow such relationships for adolescent girls (especially with adults outside the family). Rather than recommending that an adolescent “find a mentor in the community,” the clinician can say “Having relationships with adults you can trust is important. Who can you think of that might help fill that role for you?”

Table 5. Identifying strengths in adolescent statements

As adolescents mature, the behaviors indicating the development of an asset or strength will likely change. A sign of growing independence in a younger adolescent, for example, might be a new practice (such as vegetarianism, or studying a new religion) that is not shared by other member of his or her family. For an older adolescent, a more significant step away from the family, like leaving home for college in another town or state, would be a clearer (though not the only) sign of independence. The clinician’s judgment and knowledge of the adolescent, family, and community are important for interpreting whether a strength might need further development. It is also essential to get feedback from the patient. PCPs can say, “You have a close family and that is important. Developing independence [or another strength that might be lacking] is another important part of your healthy development. What steps are you taking to become independent?”

Encouragement 

Strength assessment has the dual function of informing the PCP about the patient’s overall well-being, and reminding patients and parents of what they are doing well. Professionals are able to directly reinforce adolescents’ growing competencies by simply noticing and commenting on them during routine contacts [35]. Depending on the age and preferences of the adolescent, it may also be appropriate to share information about the patient’s particular strengths with his or her parents. Practices in the VYHII found most adolescents were happy to have their parent or guardian informed of their strengths, but this may vary [54]. Table 6 offers suggestions for messages to patients (and their families, if appropriate) depending on whether a strength is present or absent. Even without an assessment framework, however, PCPs can provide general guidance and encouragement to develop personal strengths.

Table 6. Messages to patients and parents

Intervention 

Strength-based approaches have been criticized for holding a “Pollyannaish” view that denies the gravity of existing risks and challenges. Beginning with a strength assessment, however, reminds adolescents of their assets and lays the groundwork for subsequent discussion of potential changes [30]. Adolescents often think, for example, that drinking alcohol is the only way to socialize and have friends. A strength assessment can help to identify other sources of connection that an adolescent may have in his or her life. Coupled with counseling techniques such as motivational interviewing [59], reflective listening [60], and shared decision-making, the approach can help PCPs show adolescents an expanded range of options in their lives [35]. The strengths approach is valuable strategy for encouraging adolescents to engage resources, systems, and networks they might not have fully tapped into, such as after-school programs, civic organizations, faith-based groups, and relationships with family members. Keeping a list of community resources can facilitate these discussions.

Parents 

Although the strengths approach encourages adolescents’ increasing involvement in their health care, PCPs should maintain a collaborative relationship with parents. Most parents would like clinicians to advise them on their child’s development [61], and parental monitoring is itself a protective factor for adolescent health [62]. Clinicians can include parents in the strengths approach by providing them with concise information about the topics to be discussed during an adolescent well-child visit. If a particular strengths framework will be used for strengths assessment, it may be helpful to share a copy of that framework with parents. Such information can be provided prior to or during a visit. The PCP can also prompt parents to continue discussion of these topics at home by providing reading materials or sample questions.

Parents prefer advice that will help them create a positive environment for their children [63]. PCPs can offer the approach as a model for communicating with and understanding their adolescent (discussion of the overall approach need not break confidentiality). If the common goal of adolescents, parents, and health care practitioners is for adolescents to achieve independence, both home and health care environments should promote open discussion of decision-making and problem-solving. Practitioners who demonstrate a respectful, affirming attitude towards youth and who discuss youth development in terms of building strengths can help parents better understand their role in raising caring, competent, and responsible young people.

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Conclusion 

Schools, community organizations and faith-based groups have taken the lead in adopting positive youth development approaches. Practitioners who use strength-based approaches with youth build on and reinforce these community efforts, and also make a unique contribution. Exploring the youth’s developmental progress during a medical visit is an opportunity to strategically direct the youth (and their parents when appropriate) to an understanding of the adolescent’s progress and their unique set of strengths as a young person and as a family, and helps them to identify potential next steps.

A strength-based approach is not an additional part of the visit; rather, it is a way to efficiently reorganize and prioritize the content of anticipatory guidance. It turns the medical visit into an opportunity for adolescents to receive information from a trusted source about where they should be directing their energies for healthy development. This is not “foreign territory” for clinicians, who are often quite experienced in supporting the resilience of youth and families struggling with chronic illness and difficult situations. Counseling techniques such as motivational interviewing and shared decision-making, and community collaboration are essential to providing family-centered care in a medical home [51]. Similarly, collaboration toward positive youth development among PCPs, adolescents, parents, and the community can allow adolescents to transition from mere recipients of health promotion and risk prevention efforts into proactive, informed individuals who consciously make healthy choices for themselves.

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Acknowledgments 

Support and funding was provided by: The Vermont Agency of Human Services, including the Vermont Department of Health and the Office of Vermont Health Access (Medicaid), Banking, Insurance, Securities, & Health Care Administration (BISCHA), Blue Cross and Blue Shield of Vermont, MVP Health Plan, The Vermont Health Plan, the University of Vermont College of Medicine.

We are thankful to the Vermont Youth Health Improvement Initiative pediatric and family medicine practitioners and their office staff for their implementation of and feedback on the strengths approach; the representatives of the health plans and Vermont state government who funded and guided this project, the Project Coordinators who have been committed to the approach: Margaret Lewis, Don Taylor, Mary Lou Shea, and Susannah Magee; and the high school, undergraduate, medical school, and pediatric resident consultants who made significant conceptual and practical contributions to the manner in which these concepts could be used in the medical home setting: Joshua Knapp, Patrick Lucey, Jim Duncan, Sarah Logan, Sara Smoller, Allison Grenier Lafferty, Jane Orkin, Jen Carlson, Emily Hannon, Jae Vick, and Emma Vick.

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Appendix 

Additional Resources 

The new American Academy of Pediatrics violence prevention program, Connected Kids: Safe, Strong, Secure™

www.aap.org/connectedkids/

National Clearinghouse on Families and Youth

www.ncfy.com/youthdevlp.htm

The Search Institute

www.search-institute.org

The Seattle Social Development Research Group

www.sdrg.org

Ginsburg K. A Parent’s Guide to Building Resilience in Children and Teens: Giving Your Child Roots and Wings. Elk Grove Village, IL: American Academy of Pediatrics, 2006.

Benson PL, Galbraith J, Espeland, P. What Kids Need to Succeed: Proven, Practical Ways to Raise Good Kids. Minneapolis: Free Spirit Publishing; 1994.

Wertlieb D. Converging trends in family research and pediatrics: recent findings from the American Academy of Pediatrics Task Force on the Family. Pediatrics 2003;111:1572–1587.

Circle of Courage Poster. Reclaiming Youth Network. Available for purchase at: http://www.reclaimingbooks.com/catalog/product_info.php?products_id=26

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