Background
Alcohol consumption among adolescents is a major
public health problem in the United States. Despite the fact that alcohol
consumption under the age of 21 is illegal, people age 12 to 20 years drink 11%
of all alcohol consumed and account for 189,000 emergency room visits for
conditions related to alcohol each year. (1) While the underage drinking rates
have been steadily declining, the statistics still remain at an alarming level
and continue to cause senseless injuries and even death among adolescents. Despite
many efforts to reduce this behavior, the question of why adolescents choose to
drink alcohol remains at the forefront of public health debates across the nation.
In
an effort to decrease the prevalence of underage drinking, the Substance Abuse
and Mental Health Services Administration (SAMHSA) Center for Substance Abuse
Prevention (CSAP) recently launched its Underage Drinking Prevention National
Media campaign entitled “Talk. They Hear You.” (2) This intervention aims to
reduce underage drinking among youth by providing parents and caregivers with
resources they need to understand the risk factors involved with alcohol and
then address the issue with their children at an early age. Through increasing
parents’ awareness of the prevalence and risks of underage drinking; equipping
parents with the knowledge, skills, and confidence to prevent underage
drinking; and increasing parents’ actions to prevent underage drinking, (2) the
campaign aims to decrease the prevalence of alcohol use among adolescents. The foundation
of this intervention is to educate parents about alcohol abuse among teenagers
who will then use this knowledge to influence their children’s decisions about
alcohol consumption in the future. (3)
Overview of the Critique
The
strength of the “Talk. They Hear You.” intervention is inadequate based on the
social and behavioral theories and principles that contradict the components of
the campaign. SAMHSA’s approach is flawed in several aspects and will likely be
unsuccessful in reducing alcohol use among adolescents. First, the campaign
does not take into account the fact that social and environmental factors
highly influence the behavior of adolescents according to the Social Cognitive
Theory. Since teenagers spend the majority of their time in school with their
peers, social influence will play a higher role than parents when it comes to
decision-making. Additionally, the effects of psychological reactance will
cause adolescents to feel robbed of their autonomy and will therefore
counteract the intervention. They will feel the urge to rebel against their
parents by doing the exact opposite of what is asked of them. The final flaw is
that the intervention incorrectly utilizes the traditional Health Belief Model
by assuming that adolescents will rationally weigh the cost and benefits of
alcohol consumption even if fully explained by their parents. Furthermore, the
campaign falsely assumes that the parents themselves will think rationally
about the issue and fully understand the risks of alcohol consumption.
Flaw #1: The Impact of Social Learning and Modeling
on Adolescents
The main focus of the “Talk. They Hear You.” campaign
is to target parents and caregivers by offering the necessary educational tools
and resources to enable parents to confidently talk to their children about
alcohol. Parents will then present this knowledge by speaking to their children
about the risks of alcohol use. One of the main goals of the intervention is
“to reinforce the importance of talking with children about the dangers of
alcohol use.” (4) This value of the intervention does not take into
consideration the fact that their children’s environment, social scene, and media
exposure significantly influence their ability to make reasonable decisions. Children
and adolescents are swayed by these factors for various reasons; in fact, most studies
have shown that many teenagers report using alcohol because all of the “cool”
kids drink. (5) This perception of “cool” is not something that parents can
change since it is rooted in the social and environmental components of an
adolescents’ life. The intervention overlooks the vital impact of social models
on the fragile adolescent lifestyle—which does not always include parents and
guardians in the mind of an adolescent.
This
parental approach to teaching children about the dangers of alcohol use aims at
the individual for a change in behavior. According to the Social Learning
Theory, individual behavior is part of a triangle—an interaction between an
individual, their behaviors, and the environment. (6) The social and
environmental factors that influence teenager’s behavior are so strong that
parental intervention is often unsuccessful in overruling this notion. In fact,
studies have hypothesized that alcohol use behaviors are largely the result of
cognitive processes through which people anticipate the consequences associated
with their actions and act accordingly, consistent with the social learning
approach. (7) In other words, one’s personal beliefs about drinking are at the
forefront of their decisions, and those values stem from examples of others’
behavior. It only makes sense that these examples must include people that
teenagers respect and admire.
The concept of “observational learning” or “modeling”
complements this idea as it refers to the “process whereby people learn through
the experiences of credible others, rather than through their own experience.”
(8) This supports the notion that adolescents learn a specific behavior by
following a model. The “Talk. They Listen.” campaign uses parents as models,
which might work in some cases. However, since most adolescents look to their
peers as models for behavior, this campaign lacks credibility. Therefore, when
creating a campaign targeting adolescent behavior, it is imperative to take
into account the impact of social models and ensure that the models themselves
are chosen wisely.
Flaw #2: The Effects of Psychological Reactance
While the idea to talk to children about alcohol
before they reach their teenage years is well intentioned and may have some
benefits, by the time children become adolescents they reach a point in which
their independence and autonomy are of the highest importance to them.
Adolescents do not want to be told how to live their life; they want to have
experiences and learn from those experiences on their own merit. Parental
influence on their teenager’s decision to drink alcohol will likely threaten
their individual freedom and trigger psychological reactance. The psychological
reactance theory poses that if a person’s behavioral freedom is reduced, he or
she will become motivationally aroused to counterforce this loss of freedom. (9)
An applicable example of this theory is an experiment
involving 2-year-olds who are placed in a room with several toys. Beside the
toys set up for the children to play with, there are additional toys behind a
barrier that the children cannot reach. As the theory implies, the children are
inclined to play with the unattainable toys—theoretically, because it is out of
their control. This experiment exemplifies the concept that it is natural for
people want to be in control of their own choices and behavior. As a result, people
will often purposely choose to oppose a particular force, rule, or intervention
in an attempt to restore their limited freedom.
Another one of the goals of the “Talk. They Hear
You” campaign states “to inform parents to start the conversation early—before
they are teenagers.” (4) The problem with this method is that when a child
enters their teenage years, the effects of psychological reactance will inevitably
come into play and directly threaten the teenager’s freedom. In essence, a
boomerang effect will occur when teenagers are told not to drink by their
parents, and the information they were given as children will become irrelevant
when the forces of psychological reactance come into effect. Whether they were
told as children how to make decisions, adolescents thrive on testing their
parents and bending the rules by maintaining their own sense of self and making
their own choices. This inevitable attitude among adolescents will not bode
well with this intervention because they will want to make decisions on their
own when it comes to alcohol.
Flaw #3: Challenging the Health
Belief Model
The
Health Belief Model has been the traditional foundation for public health
interventions since the 1950’s and one of the first theories of health behavior.
Social psychologists, Godfrey Hochbaum, Irwin Rosenstock, and Stephel Kegels
based the mechanism on the understanding that people weigh the scale of
perceived benefits of practicing a behavior versus the opposing costs. (10) According
to the model, there are six main constructs that influence people’s decisions
about whether to take action: perceived susceptibility, perceived severity,
perceived benefits, perceived barriers, cue to action, and self-efficacy. (9) While
these elements can often be useful in exploring individual behavior, the
assumption that individuals rationally evaluate the costs and benefits of a
situation is a major flaw of the Health Belief Model as it directing ignores
elements of external and social influence. (10) Additionally, the model fails
to recognize that there are major disparities in knowledge among individuals. Individuals
hold varying levels of understanding which makes it difficult to fully perceive
the susceptibility and severity of a threat, recognize the benefits of avoiding
that threat, and then make a rational decision to act. This model fails to
consider that many individuals are unable to see reality clearly and understand
these factors because they do not always have the capacity.
With
regard to the “Talk. They Hear You.” Campaign, the flaw of the Health Belief
Model is two-fold. First, the intervention makes the false assumption that
children and adolescents will rationally decide to take their parents’ advice
and abide by their rules. The underlying truth is that adolescents have a
skewed perception of right and wrong because of social and environmental
factors that influence their decision-making skills. They may remember
conversations with their parents when they were children regarding alcohol, but
they may not take this information into consideration as an adolescent when
faced with a decision. Secondly, it is naïve to assume that the parents and
caregivers themselves will receive the message of the campaign, have the full
capacity to understand the resources, and convey that message to their children.
Another weakness in the campaign is that it essentially takes an extra step in
reaching the adolescent by connecting the parent directly and the adolescent
indirectly. Further, this information might not even resonate with some folks
who do not think rationally about alcohol consumption among teenagers.
The idea of optimistic bias is another major flaw
of the campaign among both parents and their children. Optimistic bias stems
from the idea that people tend to assume that their susceptibility to an
outcome is lower than others, and generally expect positive events to occur in
their futures. Alternatively, while individuals underestimate the risk and
probability of negative outcomes in their own lives, they often believe that
the general population is at a higher risk than themselves. Unfortunately for
the “Talk. They Hear You.” campaign, optimistic bias opposes the main function of
the intervention. If parents do not believe that their child will develop a
drinking habit, then they will not utilize the resources within the intervention
or even pay attention to the message conveyed. Parents might presume that the
campaign is a great idea for the general population, but if every parent thinks
that their child does not need an intervention, then the campaign will not be successful.
Proposed Alternative Intervention
An alternative intervention can be implemented in
order to decrease the prevalence of underage drinking on a national level that promotes
independence and freedom rather than parental influence. With that in mind, the
new intervention plan will involve a nation-wide initiative that establishes a
“peer mentor committee” at every public high school. The committee will be
called “#DrugFreeStandUp” and each high school will have its own subcommittee
title. For example, the committee at Brighton High School will be called
“#BHSStandUp” and a private school like Christian Brothers Academy that might
decide to join could be called “#CBAStandUp”. This committee will consist of
three boys and three girls in each grade level at the high school, totaling 24
students. These students will commit to a drug and alcohol free lifestyle and
will serve as peer mentors to the rest of the student body. The peer mentors
will be elected by their classmates each year, so they will be well-respected
and have a strong influence on the behavior of their peers.
To
add to the credibility of this intervention among high school students, the
nation-wide committee will be endorsed by two popular young celebrities—a male
and a female—who will also commit to living a healthy lifestyle and serve as
the faces of the committee. This group will not only surround students with
healthy choices within their social network, it will give them the illusion of
control over their lives and lead to safe choices with regard to alcohol.
Intervention #1: Recognition of the Group as a
Whole Versus the Individual
The “Talk. They Hear You.” campaign failed to
utilize the Social Learning Theory because parents were assigned as the main
models for teen behavior. #DrugFreeStandUp will properly apply the Social
Network Theory—the idea that networks of close family and friends highly influence
values and behavior—by assigning peers as models. Social network analysis,
which is a set of theories, methods, and techniques used to understand social
relationships and how these relationships might influence individual and group
behavior (11), has proven that individual substance use and misuse is strongly
associated with, and perhaps influenced by, use within one’s social network. (11)
Based
on this theory, the new intervention will have a significant impact on the
behavior of students. The nationwide attention that #DrugFreeStandUp will receive
whether through the celebrities that endorse it or through word of mouth will
encourage adolescents to want to mimic the lifestyles of their peer leaders who
will lead by example. This group will represent the new “popular” thing to do,
and members will take pride in being elected to a group that is competitive and
prestigious in nature. Adolescents crave a sense of belonging in a time that
can be physically, emotionally, mentally, and psychologically confusing. It is
important that they feel this sense of comfort in their every day lifestyle
which begins at school. By promoting their own alcohol-free standpoint, the
peer mentors will eliminate any fear of not fitting in among students who
choose not to drink.
An intervention that simply encourages parents to
speak to their children about alcohol is just not enough. #DrugFreeStandUp will
move beyond the traditional Social Learning Theory and aim toward a group level
approach. When “mob mentality” occurs, the behavior of a large group cannot be
justified by individual decision-making. In other words, an intervention must
target the group as a whole in order to make a difference rather than on an
individual level. (12) The new intervention will ensure that masses of
adolescents are reached at every high school in the nation. This is
particularly more effective than focusing on the individual through a parent.
The “Talk. They Hear You.” campaign misses a significant factor in the
influence of the adolescent lifestyle—social norms and networks. #DrugFreeStandUp
will be sure to address these crucial factors.
Intervention #2: Emphasis on the Illusion of
Control
Incorporating the illusion of control to this new
intervention will give adolescents the sense of freedom that they are making
decisions on their own. According to the illusion of control theory, people
overestimate their ability to control events. Through #DrugFreeStandUp,
students will be socially drawn to a group that happens to make good decisions
with regard to alcohol consumption. In the students’ minds, they are choosing
to do the right thing on their own. This is an illusion because in fact, the
peer mentor committee is inadvertently influencing the behavior of the students
that respect and admire the group.
The
illusion of control aspect of the new intervention is a direct improvement upon
the effects of psychological reactance in the “Talk. They Hear You.” campaign.
Rather than imposing rules upon adolescents, the new intervention gives them
the perception that they invented the rule. This illusion of control avoids the
rebellion that often occurs as a result of psychological reactance and
translates to voluntary healthy behavior and choices.
Intervention #3: A Focus on the “Big Picture”
The “Talk. They Hear You.” campaign provides
valuable material to parents that include the most up to date studies and
statistics on underage drinking. As explored earlier, the Health Belief Model
falsely assumes that parents will rationally absorb these statistics and
educate their children based on facts. #DrugFreeStandUp will be more effective
because it takes into account the fact that presenting statistics is not always
effective. The law of small numbers and optimistic bias are well-known theories
that work to design effective interventions in addressing human irrationality.
The law of small numbers states that humans struggle with probability and have
a distorted perspective on statistics. Since there is a misconception with
regard to risk, it is difficult for people to relate to numbers and therefore
are not influenced by statistics. Essentially, “Talk. They Hear You” will not
be effective because parents will often be misled by the statistics provided to
them and will therefore not convey the “big picture” to their children.
People are more inclined to behave a certain way
through single examples and personal stories rather than raw numbers sway their
decision. The new intervention will certainly provide opportunities to share
real stories about fun ways to avoid situations with alcohol which will be much
more effective than reciting data. Through monthly retreats, alcohol-free
social events, and community service activities, students will have the
opportunity to share personal stories of obstacles they have faced with regard
to alcohol and other issues in order to experience first hand the alternative
ways to have fun with their peers.
Conclusion:
The “Talk. They Hear You.” campaign fails to meet
the social and behavioral theories and concepts that consistently drive the way
people think about issues and act on them. While it is certainly important for
parents to talk to their children about alcohol and create an open environment
at home, the intervention will not solve the serious alcohol issue among
adolescents as a whole. Since each flaw in the old intervention has been
addressed by theories of social and behavioral science, there is room for
success in the near future for adolescents through #DrugFreeStandUp. The new
intervention focuses on viewing adolescents as a group rather than as
individuals, provides an illusion of control, and allows for the adolescent to
see the big picture—concepts that are vital to changing behavior. The core
value of freedom is now prevalent as the individual will make their own decisions
based on personal stories from their peers and support from leaders in their
community.
REFERENCES:
1) Centers for Disease
Control and Prevention. Fact Sheets – Underage Drinking. Atlanta, GA: Centers
for Disease Control and Prevention. http://www.cdc.gov/alcohol/fact-sheets/underage-drinking.htm.
2) Greenburg, M., Spoth,
R., and Turrisi, R. Preventive Interventions Addressing Underage Drinking:
State of the Evidence and Steps Toward Public Health Impact. Journal of the
American Academy of Pediatrics. 2008; 121:311-336. http://www.pediatricsdigest.mobi/content/121/Supplement_4/S311.short
3) Nash, S.G., McQueen,
A., and Bray, J.H. Pathways to Adolescent Alcohol Use: Family Environment, Peer
Influence, and Parental Expectations. Journal
of Adolescent Health. 2005; 37(1): 19–28.
http://www.ncbi.nlm.nih.gov/pubmed/15963903
4) Substance Abuse and
Mental Health Services Administration. Sample “Talk. They Hear You.” Materials.
Rockville, MD: Substance Abuse and Mental Health Services Administration. http://www.samhsa.gov/underagedrinking/
5) Klein, J., Schoen, C.,
and Simantov, E. Health-Compromising Behaviors: Why Do Adolescents Smoke or
Drink? JAMA Pediatrics. 2000; 154(10):1025-1033. http://archpedi.jamanetwork.com/article.aspx?articleid=351569
6)
Siegel, Michael. “Traditional Health Behavior Models.” SB721. Boston
University, Boston. 21 Feb. 2013. Lecture.
7) Grube, J., Paschall, M., and
Lipperman-Kreda, S. Community Norms, Enforcement Of Minimum Legal
Drinking Age Laws, Personal Beliefs And Underage Drinking: An Explanatory
Model. NIH Public Access. 2010: 35(3): 249–257. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2863071/
8) National
Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice.
National Cancer Institute. Part 2. 2005; 13-21.
9)
Allen, D., Sprenkle, D., and Vitale, P. Reactance Theory and Alcohol
Consumption Laws: Further Confirmation Among Collegiate Alcohol Consumers. Journal
of Studies On Alcohol. 1994; 55: 34-40. http://www.jsad.com/jsad/downloadarticle/Reactance_Theory_and_Alcohol_Consumption_Laws_Further_Confirmation_among_C/2147.pdf
10) Edberg,
M. Individual Health Behavior Theories. (pp. 35-49). Essential of Health Behavior: Social and Behavioral Theory in Public
Health. Sudbury, MA: Jones and Bartlett, 2007.
11)
Gallagher, P., Mouttapa, M., and Valente, T. Using Social Networks to Understand
and Prevent Substance Use: A Transdisciplinary Perspective. Substance Use &
Misuse. 2004; 39 (10-12): 1685-1712. http://www-hsc.usc.edu/~tvalente/Publications/valente%20et%20al%20SUM.pdf
12)
Siegel, Michael. “Alternative Models.” SB721. Boston University, Boston. 7 Feb
2013. Lecture.
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