monitoring and constant readjustments of program quality are necessary to maintain momentum. A case in point is the South Carolina example mentioned above -- pregnancy rates climbed back to original levels three years after the intervention when access to contraceptive services was reduced and trained teachers left the school system. 25 Program planners in Maryland, recently named the model state in adolescent pregnancy prevention by the Southern Governors' Association, have deemed comprehensive services the most promising approach. At the June hearings, Bronwyn Mayden, Executive Director of Maryland's Governor's Council on Adolescent Pregnancy, offered a partial explanation for the need for comprehensive services: Different strategies are needed [because] adolescents are not 26 This Gardner also emphasized this point in the context of HIV prevention: At present, efforts to reduce risky behaviors among 27 In summary, it is not unusual for adolescents to exhibit an increase in knowledge, or to report changes in their attitudes about sex as a result of participation in a single-mode intervention. However, teens appear to alter behavior patterns only if they receive a repeated, consistent message, develop the skills to make use of it, and have support for change from groups with whom they identify. Generally, in order to display marked effects of training, youth must participate in the majority of the sessions in a prevention curriculum,29 and have access to necessary health services. Individual attention from adults appears to be particularly important for youth at high risk.30 28 C. AIDS RISKS AND OTHER RISKS ARE RELATED Adolescents who are prone to take risks often exhibit more than one kind of risky behavior.31 Thus, strategies shown to be successful in preventing smoking, drug abuse and other sexually transmitted diseases in adolescents may well apply to HIV prevention.32 For example, studies of smoking cessation programs have shown that attempts to frighten teenagers are not particularly effective, and can sometimes backfire.33 Interventions designed to prevent HIV infection should convince young people that they can become infected, while not raising anxiety levels to the point of creating denial, hopelessness, or negative effects on sexual development.34 In turn, effective HIV prevention programs should lower the prevalence of other problems caused by the same high-risk sexual and drug use behaviors that transmit HIV infection.35 Several witnesses at the June hearings told the Committee that narrowly targeted preventive efforts (such as the Drug Free School Program of the Department of Education) should be broadened to address other HIV-related risks.36 Lloyd Kolbe, Director of the Division of Adolescent and School Health (DASH) of the CDC, advised the Committee that it would not be difficult to develop prevention techniques that address interrelated risks, noting that "CDC has designed its current program principally to prevent behaviors that result in HIV among youth...[but] it can be adapted to address other priority risk behaviors."37 Experience in school settings suggests an expansion of the focus of HIV prevention programs to other health-related behaviors wherever possible. Testimony submitted by the Human Rights Campaign Fund tracked the evolution of a model preventive program targeting gay and lesbian youth in the Los Angeles schools: ...into a general counseling and educational vehicle for both model provides for education, school safety, drop-out Research in a variety of settings has documented the success of a comprehensive approach to prevention of high-risk behavior. Joy Dryfoos, author of a recent book reviewing the adolescent risk prevention literature, has pointed out that: The most successful programs [appear] to be focused on the 39 Underlying problems that Dryfoos found predictive of highrisk behavior include: a lack of basic skills or of parental support; little ability to resist peer pressure; living in a disadvantaged community; and, feelings of depression and stress. D. KNOWLEDGE OF ADOLESCENT PSYCHOLOGICAL DEVELOPMENT CRITICAL TO PROGRAM DESIGN Taking the psychological development of teens into account when designing HIV prevention programs for this population presents considerable challenges, but it is essential that they be addressed. Adolescent psychology has been characterized by its strong orientation to peer culture, illusions of personal invulnerability, and natural tendency towards risk-taking." Dorothy Wodraska, a witness at the Select Committee's June prevention hearings from Project I-STAR (Indiana Students Taught Awareness and Resistance), a drug prevention program with demonstrated effectiveness in changing adolescent behavior, explained that middle school is a prime point for intervention because: ...young people are more susceptible to peer influence at this Furthermore, young adolescents' thinking tends to be concrete and egocentric, and not to be future-oriented. Two important skills increase during adolescence: The ability to anticipate the consequences of one's actions, and the ability to integrate specific facts into a general, coherent framework.42 Future consequences and implications of specific behaviors should be clearly articulated in teen-oriented prevention programs.43 There is also evidence that children and adolescents use decision rules different from those of adults in making moral judgments.44 Thus, forcing one limited version of morality on teenagers not only ignores the diversity in moral positions adults hold (a misrepresentation teens are likely to discern), but may also prove futile because of the way teenagers think.46 45 Optimally, all adolescents should be developing self-control and the ability to form mature intimate relationships.47 From one point of view, then, making decisions about substance use and sexual experimentation can serve to fulfill basic developmental needs.48 Ironically, this "normal" behavior can have life threatening consequences. An HIV prevention instructor's credibility can hinge hinge on acknowledging the contradictions in society's messages to adolescents.49 E. HOW TO DELIVER CRITICAL AIDS MESSAGES Experts recommend that certain specific facts should be imparted in HIV prevention classes, such as the relative superiority of latex over lambskin condoms in blocking transmission of the virus.50 However, the most important single message for adolescents may be: "It is not who you are, but what you do that places you at risk of AIDS." Emphasizing risk groups to teens can lead to self-labeling as immune. When the HIV virus is present, needle sharing among athletes using steroids can be just as deadly as unprotected sex with an IV drug user." 51 message will be salient to from smoking prevention is likely that physical ful to 12-year-olds, will increase in importance with age.52 Descriptions of immediate effects of highrisk behavior should be more compelling to adolescents than long-range impact.53 The OTA Adolescent Health report advised that the way information is transmitted may be important in students' ability to retain new knowledge. The OTA review provided support for multi-media presentations, active participation, and the use of role models to alter misconceptions and inoculate against media influences.54 Even when programmers take care to present essential information in the best possible form for a specific age group, information alone may not be sufficient to prevent high-risk behavior. Knowledge gains do not guarantee change in general attitudes, intentions to change specific behaviors, or change in high-risk behavior itself.55 OTA illustrated the limited value of information alone with the finding that, although most students know that condoms will help protect them, less than half of all adolescents who are sexually active use condoms, and only half of those who use them do so all the time. Moreover, perceived risk of AIDS did not predict condom use in a sample of adolescents at a family planning clinic in Baltimore,56 or in runaways in New York City.57 A dramatic increase in condom use was noted, however, when the full range of needs of a group of runaways was addressed by a comprehensive demonstration program. 58 59 While research supports the recommendations made above, an important caution emerges from the same scientific literature. Well designed prevention programs (such as smoking cessation efforts) targeting adolescents have been somewhat successful with white, middle-class youth. However, with rare exceptions such as a recent project sponsored by the Rand Corporation, most evaluations have failed to demonstrate behavior change in minority youth. It may be possible to strengthen prevention programs for minority youth by finding out more about perceived meanings of high-risk behavior as they vary by gender, ethnicity, and social demographics. Involving parents and peers in the design of prevention programs should be useful in this respect, |