1. What Influences Young People’s Decisions To Take Risk? Assoc Prof John Scott Centre for Young People’s Health, The University of Queensland jscott@hms.uq.edu.au

2. A spectrum from “need a little help” to “don’t care”?  Risk-taking behaviour - “volitional behaviour in which the outcomes remain uncertain with the possibility of an identifiable negative health outcome”  About 13% of teenagers fit the “risk-taker” profile  Six categories of risk-taking behaviour  Unsafe sexual activity  Violence, accident and injury  Alcohol and other drug use  Use of tobacco products  Poor nutritional habits  Minimal physical activity  Presence of chronic physical or mental health problems or disabilities increases these risks further

3. Risk-taking  Becomes more common in 10 – 24 year age group  Associated with changes in patterns of morbidity and mortality, some temporary, some permanent  Part of normal adolescent development, but is not consistent for all young people  An important life-stage for determining the lifestyle an individual adopts  Transition process actively under the control of the individual but is also strongly influenced by the environment in which they live  General characteristics of high-risk youth  low school achievement and low basic skills  lack of parental support (often due to parental health and behaviour problems)  background in a disadvantaged racial group  low resistance to peer influences  early “acting out” in any of the behavioural domains  residence in an impoverished neighbourhood.

4. Young people have been described as existing in four worlds Peer World Family World Inner World School World Dr Michael Carr-Gregg, Albert Road Centre for Health

5. The inner world… A person’s perception of the world determines their likely behaviour. Likelihood of action is defined by perceived benefits minus perceived barriers. Major concepts are:  individual perceptions eg  perceived susceptibility to serious outcomes  perceived seriousness of outcomes  modifying factors eg  demographic variables  psychosocial variables  structural variables (knowledge, previous experience with health promotion etc)  and the individual’s  perceived threat of adverse health outcome  perceived cues to action (mass media campaigns, advice or encouragement from others)

6. Individual perceptions are inherently subjective and influenced by personal biases. Adolescent issues…  availability bias  how easily the event can be brought to mind  influenced by frequency of the event, personal experience of the event, memorability of the event and vividness of the memory  note potential impact of the media  adolescents don’t have a lot of experience to draw on and until they have a negative experience their lack of a negative experience may foster their bias  representativeness bias  where correlates with one attribute of a person generate biased perspectives on other attributes  no more likely in adolescents than in adults  inferential biases  more likely to view one’s own situation as more favourable than others in a similar position  no more likely in adolescents than in adults  attributional biases  optimistic approach, never my fault, I am doing everything I need to do to avoid unfavourable outcomes – no more likely in adolescents than in adults Overall, there does not appear to be any evidence to support an adolescent view of invulnerability that ignores “reason”

7. The family world and the peer world… The information young people receive, and on which they base a lot of their risk-related decisions is variable and difficult to categorise. Factors to consider and which might be able to be influenced include:  strength of evidence  bias of the information-provider  social/political leanings of the provider  intent of the provider (eg to sensationalise or play down the strength of a message)  goal of the provider (eg to promote consumption of a product or to limit a behaviour)  authoritative stance of the source (parent, teacher, peer, or media) Sociologists describe influences on young people:  increasing individualisation, at the same time as  increasing conformity and control, associated with  increasing individual isolation as the risks of the world are interpreted as personal and solutions to these risks are perceived and also portrayed as requiring an element of personal responsibility

8. Where the inner world meets the family and peer worlds is a dynamic place… Risk-taking reflects interactions between  the adolescent’s developing personality system  the environment perceived by the young person  their developing behaviour system

9. The Personality System…  researchers recognise adolescent health risk takers and propose sensation seeking (seeking varied, novel, complex and intense sensations and experiences, with a willingness to take physical, social, legal and financial risks for the sake of such experience) as an index for this behaviour type. They also describe sensation avoidance.  researchers propose that humans have individual levels of need for stimulation at which they are most comfortable and this affects attention. However high sensation seekers are not necessarily impulsive and we need to differentiate the two traits.  for designing prevention messages for young people researchers propose we (a) use sensation seeking as a targeting variable (b) conduct formative research with target audience members (c) design high sensation-value prevention messages, and (d) place messages in high sensation-value contexts eg television programmes exciting to the target audience.

10. The perceived environment and health-promoting settings…  adolescent beliefs and interpretations of risk are related to social and/or cultural experiences and knowledge and also to developmental differences in interpretation of risk, relationships and prevention messages.  the social environment of a school and the overall quality of students’ relationships with teachers and with other students is important.  teachers’ judgments are critically important and evidence suggests their classroom assessments are better than parents’ and peers’ in assessing future student outcomes But “environment” is a “fluid” concept

11. Translating personality and environmental interaction to behaviours… Problem-Behaviour Theory  Young people’s perceptions of their environment are dynamic and based on variables in play at that particular time  Behaviour is the outcome of the interaction between the young person’s personality and this perceived environment  The perceived environment includes:  ‘distal’ variables - perceived support from parents, perceived support from friends, perceived controls from parents, perceived controls from friends, parent-friends compatibility of expectations, and relative influence of parents and friends  (more important?) ‘proximal’ variables - friends’ approval or disapproval, parents’ approval or disapproval and friends’ models of particular behaviours important at the time)  Within the young person’s personality system three goals are thought to be particularly salient – peer affection, academic success and independence  Behaviours thought to constitute a ‘problem’ are not defined intrinsically by the young person but are defined by the norms of conventional society and by adult authority. Personal belief structures then may or may not prevent the young person from engaging in these problem behaviours and these structures are classified in four domains – social criticism, alienation, self- esteem and internal-external locus of control.

12. Translating personality and environmental interaction to behaviours… Refinements of Problem-Behaviour Theory:  Resilience or a capacity to be “shielded” from negative environmental influences by what were defined as “protective factors”  Protective factors considered to fall into three groups:  positive behaviours in the young person’s personality or adaptive temperament  a stable, cohesive and supportive family  social and cognitive skills attained in a nurturing school environment

13.  Protective factors within the individual:  Temperament  Beliefs  Skills  Sense of humour  Internal locus of control  Early communication  Positive self-image  Religiosity  Competent academically  Prone to engage in self-care strategies  Intolerant of “deviance”  Engaged in extra-curricular activities  Protective factors within the family: Parents who:  Are caring and concerned  Are at home at key times of day  Have high expectations of academic performance  Disapprove of health-risk behaviours  Have not had prolonged separation from their children Families with:  Both parents in the home  Fewer than four children  Cohesion and structure  Protective factors within the community:  Caring adults  Peers  Access to resources  Positive role-modelling by adults  Easy access to supportive resources  Normative expectations  Communities exhibiting prosocial values and behaviours  Value placed on adolescents’ contributions to the community  Clear and consistent boundaries Relevant influences, and how achievable is “resilience”?

14. Translating these to behaviours… Further Refinements of Problem-Behaviour Theory:  “Contextualism” theory of adolescent development  Single outcomes are the final consequence of a long train of influences, some individual, some environmental  The theory recognises positive environmental influences or protective factors and also negative influences  Cannot say with certainty what a set of influences will create in terms of outcomes for a young person; we can only be probabilistic about what is likely or unlikely  “Judgement” (more than pure cognition) is likely to be very important, where judgement is influenced by the young person’s sense of responsibility, of perspective, and temperance

15. And just to make it more confusing…  Recent functional MRI evidence suggests significant variation in timing of brain maturation  The pre-frontal cortex in particular appears to be the last part of the brain to develop  Recent research suggests this area is intimately associated with research-based measures of cognition, decision- making and judgement, in controlling aggression and other impulses, in governing “impulsivity, judgement, planning for the future, foresight of consequences, and other characteristics that make people morally (and criminally) culpable”  The process and its impacts are further “complicated” by the effects of increasing but unstable levels of sex hormones particularly for males, and the timing and psychosocial effects of pubertal maturation.

16. To achieve their potential, children and adolescents need: “families who love and care for them; friends who cherish and stand by them; communities that respect and include them; a world that makes sense to them and a future that offers them hope. They also need, at least some of the time and in some respects, freedom from all these things, or from what they imply; freedom from care, from media intrusion, manipulation and exploitation, from adult intervention, supervision and worries; freedom to be themselves, to explore their world, to take risks, to set their own pace.” “Well & Good,” Richard Eckersley

17. Evidence from the area of drug use…  indications are that behaviours can be influenced by social factors  awareness of risks will influence use and increased risk perception has been followed by decreased use in a number of substances  role models (both positive and negative) are important in influencing young people’s behaviours  advice to “Just say no” is not sufficient for prevention. Evidence is young people do have some capacity to differentiate between levels of risk and engaging groups in discussion about the problems, the risks and strategies to avoid the negative outcome are all worthwhile

18. Evidence from the areas of smoking and sexual behaviour…  willingness (as distinct from preparedness) to engage in a risk behaviour is a less thoughtful reaction to a risk- conducive situation (involving relatively little precontemplation or consideration), and involves less internal attribution of responsibility for the behaviour or its attendant consequences. This suggests one intervention might be to facilitate adolescents’ contemplation of the situation and their responses before they are in the situation. This is something that can especially be supported by parents  for young people, immediate short-term costs and benefits loom larger than long-term costs or benefits. This implies time perspective should be considered in interventions with emphasis being placed on communicating explicitly the longer-term costs and benefits as part of the strategy

19. In promoting positive behaviours in young people, it is important to…  recognise social influences, including media coverage, and promote or address where appropriate  consider the influence of role models, both negative and positive  appreciate that telling them to “Just Do It” may not be sufficient  engage in discussion to:  determine whether saying they will can translate into committed action  ensure they fully appreciate long-term benefits and costs

20. Getting the message across, or how to harness the resources at hand… Two relevant perspectives, “Epidemic Modelling of the Onset of Social Activities (EMOSA)” and the Tipping Point model, recognise a number of activists and concepts as being important:  “Mavens” who hold and pass on relevant important information  connectors who know the networks and are good at passing information around  salesmen who are good at getting their friends to change their behaviour  “the Law of the Few” which says some people matter more than others  “the Stickiness Factor” which says there are specific ways of making a contagious message memorable  “ the Power of Context” which says the key to getting people to change their behaviour sometimes lies with the smallest details of their immediate situation.

21. To make a difference, it is important to:  understand the beliefs and attitudes of the “audience” and “use” and strengthen the culture and relationships of the school – teachers know these best  identify the “sensation seekers” and keep them entertained (within reason!) – usually the others will follow  use the most stimulating media and messages wherever possible  understand and use the influential student dynamics and contexts relevant to your message

22. The message form and the evidence… the evidence on which to choose the best message is very thin. five influences are recognised: –(a) perceptions of severity of outcome – weak, mixed evidence –(b) perceptions of vulnerability to outcome – weak, mixed evidence –(c) perceptions of extrinsic and intrinsic rewards vs costs for participating in the risk or protective behaviour – strong evidence across time, environments and issues –(d) perceptions of the effectiveness of the protective behaviour – weak, mixed evidence –(e) perceptions of one’s ability to conduct the protective behaviour – weak, mixed evidence. intervention options include: –face-to-face “boosters” - reinforce old messages, present new ones, provide correct information, potentially build on social interactions developed in earlier sessions, and enable interactive question-and- answer exchange, but probably only useful for two sessions –mass media - particularly effective for changing perceptions of peer norms, can alter perceptions of severity and vulnerability, unlikely to alter perceptions of self-efficacy, or of intrinsic reward or core values. –parental monitoring – the most important for sustaining and broadening the effect

23. Message topics…  topics where there is agreement are likely to have a higher rate of success when designing a campaign  depending on the behaviour being addressed, young people with different perceptions of risk may have different perceptions of health-related issues and different beliefs about positive and negative consequences eg “alcohol at a party always causes trouble”, or “people who don’t drink always have more fun”  there will be issues on which both high and low-risk groups will agree eg “accidents when drunk can cause serious injury”, or “hydration is an important issue at dance parties” though they are likely to differ on the magnitude of the effect

24. Delivering the messages…  evidence for the most effective approach is thin  stimulating an appreciation of the potential rewards for the young person has by far the best evidence  face-to-face discussion and media are useful but parental support is the most effective  choose topics of focus for which all young people can see a positive, even if some will be more in agreement than others

25. Things that work…  intensive individual attention (often reflects a role as a surrogate parent)  early intervention  focus on schools (school as an experience school as a site)  services provided in schools by outside organisations, including bringing the funding  comprehensive multi-agency, communitywide programmes  parents have a defined (real) role  peers (maybe also high-risk) have a defined (real) role  arrangements for training of teachers, including funding and release time  need to link to the world of work

26. Things that don’t work…  providing information only, with no change to social skills  “saying ‘no’” or “Just Do It” programmes  scare campaigns  programmes for high-risk kids that isolate them  special “cultural” programmes  stigmatising children – may be better to have special programmes for high-risk schools based on local demographics.

27. Youth development programs (United States)… Eight features for positive developmental settings:  physical and psychological safety  appropriate structure  supportive relationships  opportunities to belong  positive social norms  support for developing efficacy and building a sense of “mattering”  opportunities for skill building  integration of family, school and community efforts.

28. Powerful addictions Peer pressures Social taboos Vested commercial interests Ingrained social values Huge & increasing rates Unknown causes We know behaviours can be changed to improve health despite:

29. Powerful addictions - tobacco Peer pressures - wearing sun hats Social taboos - AIDS & safe sex ads Vested commercial interests - tobacco Ingrained social values - tanning Huge & increasing rates – heart disease Unknown causes – cot death We know behaviours can be changed to improve health despite:

30. Winning the Fight Against Road Deaths 15 - 19 year old males

31. We just need the right level of investment and a supportive environment for change

32. Good Luck