1. Behavioral problems in adolescents
Doç Dr Müjgan Alikaşifoğlu

2. Adolescence, is a period of transition that for the most part are culturally determined and personally defined.
Most morbidity and mortality in this age group is atributable to preventable risk factors.

3. Threats to healthy youth devolopment
Personal and familial characteristics
Quality of the schools they attend
Communities in which they live

4. Greatest risk to healthy development of adolescents
Their behavior (i.e. Risky behaviors)

5. Adolescent risk behaviors
Behaviors that can directly or indirectly compromise the well-being, the health and even the life course of young people

6. They can result in negative outcomes or adverse consequences.
I.e.,drug use can lead to trouble with parents or the law
Early sexual activity can lead to unintended child bearing; school dropout can result in chronic unemployment.

7. Risk behaviors can be considered, therefore, as risk factors for personally or socially or developmentally undesirable outcomes.

8. Adolescent risk behaviors
Werner and Smith (1992)
Children at risk for negative outcomes (poverty, family instability, health problems)
Many of the children experienced negative outcomes as they entered adolescence and adulthood
One third became competent and successful adults

9. Why some who are reared under adverse circumstances become competent adults while others do not appear to overcome the adversities experienced in early life?

10. Resiliency
The process in which individuals show positive outcomes despite adversity
Is not a trait, it is a pattern of behavior
It represent an interaction between the individual and the environment

11. Resiliency Resilient individuals are: Flexible Not invulnerable*
Not unable to be defeated**
*Resilience refers to avoiding the problems associated with being vulnerable.
** Cumulative risk can defeat the most resilient individual.

12. Resiliency Resiliency is interactive with risk.
Resiliency refers to the process of overcoming the negative effects of risk exposure
A key requirement of resiliency is the presence of both risks and promotive (protective) factors

13. Risk factors
Elements and experiences in a child or adolescent’s life that increase the likelihood of negative outcomes and decrease the likelihood of positive outcomes

14. Risk factors Effects of risk are cumulative
Multiple risk factors at a single point in time or over time increases the likelihood of negative outcomes.

15. There is great heterogeneicity in the linkage between involvement in risk behaviors and the likelihood of adverse outcomes.
There is also great heterogeneicity in the linkage between exposure to risk factors and likelihood of involvement in risk behaviors.

16. It is this heterogenecity or variability on both the antecedent and the consequent sides of engaging in risk behavior that has led to an important new focus of inquary concerning adolescent risk behavior, namely, the identification and assessment of protective factors.

17. Protective factors
Protective factors have both direct and indirect effects;
they lessen the likelihood of engaging in risk behaviors, or of adverse outcomes from having engaged in them,
but they also can serve as moderators of or buffer against exposure to risk factors or actual involvement in risk behaviors themselves.

18. Protective factors Assets Positive factors that reside within the
individual
Competence, coping skills, self-efficacy
Resources
Positive factors that are external to the
Parental support, adult mentoring,
community organizations

19. Risk- protective factors
Effects not uniform across social groups
May operate in different ways at different stages of development or at different exposure levels

20. Risky behaviors Significant public health problem Substance use
Violent behavior
Unsafe sexual practices

21. Three behaviors Pose considerable health risks to adolescents
Play significant role in adolescent development
Amenable to public health intervention

22. Increasing public health concerns related to adolescents
Mental health disorders
Obesity

23. Sexual behavior Initiation of sex Level of sexual activity
Risky sexual behavior

24. Adolescent sexuality
Human sexuality can be defined as including the physical characteristics of and capasities for specific sexual behaviors, together with psychosocial values, norms, attitudes and learning processes that influence these behaviors.

25. It also includes a sense of gender identity and related concepts, behaviors, and attitudes about the self and others as women or men in the context of one’s society.

26. Biological factors such as genotype and its phenotypic expression begin to affect sexuality from the moment of conception. Other influences begin at birth.

27. First, the family’s attitudes and expression of femaleness and maleness, rooted in the family’s culture and influenced by society as a whole, is expressed to the infant from birth onwards.

28. From the moment the newborn’s genitalia are seen at birth, a whole set of expectations and gender-specific attitudes are elicited from the family members.
These expectations and attitudes are largely a result of the parents’ cultural dictated norms.

29. Family:
A chid’s first sense of its gender and what that means is conveyed by the parents early in childhood. As the child developes, it withnesses how the mother behaves as a woman, how the father expresses his masculanity, and how they behave with each other.

30. Since children learn best from the examples set by the most significant adults in their lives, these impressions are instrumental in helping the child define what a man or a woman should be, and how they will express themselves as members of their gender.

31. Absence of someone who fills the parental role can make it difficult for the child to understand the ways in which men and women behave with each other.
Girls “test” how to behave as women with their father or other men serving in the parental role.
Without this opportunity to “test out” in a safe relationship, girls may start “looking for daddy” and may engage in considerable risk taking behavior toward that end.

32. Inappropriate behavior on the part of the girl’s male parental figure may also negatively color her views of how to express her sexuality.
A girl or boy who is reared in a home in which the parents are caring, lowing, supportive, and affectionate toward each other most likely will be able to enter into mature, positive relationships when tehy reach adulthood.

33. Culture:
The adolescent’s expression of sexuality is greatly influenced by the culture in which she or he lives.
Culture assings very specific or less than clearly specific roles to men and to women.
When these roles are clearly defined, the choices open to the adolescent to express manhood or womanhood a few.

34. Cultural ambiguity regarding sexual behavior leaves the adolescent with many options but little guidance.
Similarly, how sexual feelings are expressed can be culturally dictated.

35. Society:
The media exerts a powerfull influence on adolescents by exposing them to an adult world of which they were unaware.
Many parents abdicate their responsibilities in teaching their children about sex and sexuality, leaving to peers and the media to be the major sources of information and role modeling in this area.

36. Negative consequences of adolescent sexuality
Premature sexual activity
Pregnancy
Sexually transmitted diseases
Sexual preferences
Gender identity issues

37. Substance use is an individual-level risk factor for adolescent sexual behavior
This risk factor is compensated for by:
a) Personal assets
b) Resources

38. Personal assets compensating for the risk of substance use for sexual behavior
Self-esteem
Participation in extracurricular activities
School achievement and attachment
Religiosity
HIV and reproductive health knowledge
Positive attitudes towards condoms
Safer sex intentions
Seeing sex as nonnormative
Self-efficacy to refuse drugs and use condoms

39. Resources compensating for the risk of substance use for sexual behaviors
Father’s education
Teacher support
Residence with both parents
Peer norms for sexual behaviors
Family socioeconomic status

40. Other risk factors for adolescent sexual behavior
Peer sexual behavior
Mother having had a child before 20 (sexual intercourse before 16)
Neighborhood poverty

41. Peer sexual behavior compensated by
Family socioeconomic status
Parental monitoring
Open parental communication

42. Mother having had a child before 20 compensated by
School attachment
Self-easteem

43. Neighborhood poverty counteracted by
Participation in extracurricular activities and community organizations

44. Substance use in adolescents
Adolescents use drugs as:
An escape from environmental chaos
A way to mirror an adult lifestyle
A rite of passage into puberty
A way to cope with adolescent issues
A result of other dysfunctional processes
A result of pervasive influence of the media and their peers

45. A way of challenging authority
A way of fitting into a social situation at school, at work, at social clubs (gang)
Media influences
Comorbid conditions (eg, depression or anxiety) also contribute to the development and maintenance of drug abuse

46. Risk factors for substance abuse in adolescents
Genetics:
Alcoholism among first or second degree relatives
Male gender
Individual
Abuse
Antisocial behavior
Parental rejection
Aggressive temparament
Lack of self control
Early sexual activity
Depression
Low self-esteem
Attention-deficit disorders
Poor self-image
Body modification
Learning disorders

47. Family:
Disfunctional family dinamics
Permissiveness
Authoritarianism
Parental conflict, divorce, separation
Poor supervision, lack of supervision
Poor parental role modeling

48. Community/environmental/societal:
Easy availability of drugs and alcohol
Cultural and religious sanction
Acceptance of drug use behavior
Unemployment
Poor general quality of life in the neighborhood
Media influence
Criminal activities in neighborhood
Low religiosity
Increased use of drugs and alcohol in certain culture

49. Peer group influence
Drug using friends
Curiosity
Rebellion
Desire to belong
Independence
Risk taking behavior

50. School/academic
Poor school performance
Poor school environment
Truancy

51. Factors protective of substance abuse in adolescents
Good communication within family
Supportive parents
Intact family
Appropriate adult supervision
Positive self-esteem
Social competence
Academic success
Good school
Good general health
High intelligence
Positive adult role models
Peer group with positive personal attributes
Religious involvement
A personal sense of morality

52. Some drugs (eg., tobacco, alcohol, and marijuana) are called gateway drugs, in that they are the launching pad for more serious drug experimentation and abuse

53. Stage of substance use Stage 1: experimentation
Usually begins in elementary or junior high
Often involves “gateway” drugs
Used in context of exploring new behaviors and experiences
Used in setting of home or party, or while “hanging out”
Used in response to peer norms or to feel grown-up
Small amounts used withhout a definite pattern
Helps adolescent to cope with demands of development

54. Stage 2: Exploration
Progression in frequency of use,
Stronger drugs used
Episodes of use may be justified as “handling stress”
Patterned use apparent and often integrated into social situations
Used during the week in conflict with regular activities (eg., school)
Problems related to drug use occur (decreased performance)
Often dissociates from non-drug using friends
Deceptive behaviors to obtain drugs
Mood swings become apparent to family and friends
Denial often predominates

55. Stage 3:Encapsulation
Tolerance develops to particular drug of choise
More and more time spent ascertaining the drug experience
Drug use to maintain function and mood
Drops out of other activities, drug use dominates life
Other problem behaviors manifested (stealing, lying, violence)
Physical withdrawal may occur
Health problems may be manifested

56. Stage 4: Dependence
Increasing negative feelings toward self
Deterioration of social relationships
Social contacts limited to drug-using friends
Denial of drug use as a problem predominates
Involvement in illegal activity to maintain drug habit
Life is chaotic in all domains (physical, social, psychologic, personal)
Often shame, guilt and self destructive behavior
Drug use not to feel “high” but to feel normal

57. Violence
Globally, youth violence has been identified as a major health problem
Violence in the lives of infants, children, and adolescents can produce debilitating effects on their growth and development.
Exposure to violence increases the risk of morbidity and mortality for all youth

58. There are various factors, including the influence of genetics, hormone production, the combination of cultural and environmental conditions, and specific form of mental illness.
In recent years the impact of exposure to violence on children and adolescents has been recognized as a major contributor to the epidemic of children’s and adolescents’ violence.

59. Children are witnessing violence at home, in their communities, at schools, and in the media.
This continuous exposure combined with easy access to firearms, alcohol, and drugs has contributed to the sudden surge of violence

60. Most violent youth do not suffer from mental illness during childhood or adolescence and these with neurological impairements, psychosis or head trauma.
These adolescents are greater risk of becoming violent, because they have psychological events that interfere with their ability to correctly interpret reality and to appropriately interact with others.

61. Most adolescents who engage in violent behavior engage in transient violence and are not violent after they become adults.
Most violent youth will never be arrested for a violent crime.
There are two general onset trajectories for youth violence.
The first onset trajectory begin before puberty, and the second begins during adolescence.

62. Those youth who become violent before age 13 generally commit crimes more often; their crimes are more serious, occur over a greater duration of time, and more frequently extend into adulthood.
Adolescents who engage in late onset violence usually are looking for excitement and are typically violent in the company of friends.

63. Definition of violence
WHO
Threatening or using power against oneself, another person or against a group or community that
-Results in
-Has a high likelihood of resulting in
İnjury
Death
Psychological harm
Maldevelopment
Deprivation

64. Form of violence
Physical intimation
Corporal punishment
Physical abuse
Physical fighting
Suicide
Physical assults
Rape
Sexual assault
Sexual abuse
Gunshot wounds
Conflicts between or
among:
Parents
Siblings
Relatives
Care providers
Teachers
Friends
Acquaintances
Other peers
Intimate partners
Spouses

65. Five factors have a major impact on the
incidence and prevalence of physical
Aggression and violence in the lives of
children and adolescence:
Exposure to media violence
Bullying
Weapon carrying
Belonging to a gang
Abusing substances

66. Individual risk factors
If the child or adolescent is/has/:
Congenital abnormalities
Low birth weigh
Low self-esteem
Beeing male (except sexual violence)
Between the ages of 15-19
A member of a violent family
Dating
Angry after experiencing a violent trauma
A member of a gang group
A runaway from home
Homeless

67. Abusing drugs
History of early aggressive behavior
A comorbid psychiatric diagnosis of: Attention deficit hyperactivity disorder, Conduct disorder
A low IQ
Poor academic performance
A learning disability
A history of physical or sexual abuse
Peers who are violent
Access to a weapon

68. If the child or adolescents:
Believes violence is effective for resolving conflicts
Accepts that violence or aggression is normal
Carries a wepon
Engages in antisocial behavior and hostile talk with others

69. Familial risk factors If the child or adolescent has:
Antisocial parents
Physically aggressive parents
Parents who use harsh physical punishment to discipline
Poor supervision by parents
A mother was parent at an early age
A family with low socieconomic status
A parent who abuses alcohol or other substances

70. If the child or adolescent experiences:
Parental conflict in early childhood
A low level of attachment with parents
Parental separation or divorce at a younger age
A low level of family cohesion

71. Environmental and cultural risk factors
If the adolescent:
Lives in an urban area
Attends a large urban school that serves the very poor
High density and overcrowding
High crime rate
Easy access to drugs and alcohol
Lack of community cohesion and neigborhood commitment
Lack of supportive services such as child care and recreation

72. If adolescent lives in area where there is:
Income inequality
Rapid demographic changes in the youth population, urbanization
A culture does not provide nonviolent alternative for resolving conflicts

73. Individual protective factor
Ability to respond quickly to threatening events
Pleasure and satisfaction in helping others
Maintaining positive expectations about the future

74. Family level protective factors
A warm family
Less crowded and clean homes
Discipline style
Strong parental supervision
Understanding and support
Closeness
Respect for individual autonomy
Good communication

75. Community level protective factors
Gun control
Legal regulation

76. Physicians role
Physicians can be involved in helping prevent/reduce risk behaviors
1-Personal level
2-Practice level
3-Patient level
4-Parent level
5-School level
6-Community/society level

77. Historical approach
Adolescent: Problem to be solved
Risk reduction strategy and treatment (Outcome is
important)
Contemporary approach
Adolescent: Resource to be developed
Adolescent development approach
(Resiliency based approach)

78. Resiliency- based approach
Builds on individual strengths
Aims at addressing those factors that predispose an individual to one or multiple risks

79. Pregnancy prevention program (risk redaction)
To develop resistance skills among adolescents at risk for early onset of sexual activity and unprotected intercourse

80. Adolescent development program
Focuses on issues related to school failure, vocational options, adult mentorship
Improving life outcomes
Reduction of unwanted pregnancy