Social Problems

1. Social Problems A Cost Effective Psychosocial Prevention Paradigm

2. Introduction • From a cost-benefit perspective, the interventions the social service system has chosen are extremely costly and highly unproductive for both client and practitioner in terms of targets, timing of intervention, ages, and contexts. • Social, cognitive, and academic skills that adults must master should provide the focus for intervention from a life-span development perspective.

3. Prevention Versus Remediation • Prevention is especially appropriate to dealing with the problems of the young. • Prevention provides an early developmental focus for intervention, which may forestall development of future problems. • Prevention provides a view of the person that is optimistic. • The approach is economic and mass-oriented rather than individual-oriented and seeks to build health from the start rather than to repair damage that has already been done.

4. Prevention • The life skills training intervention model is proposed as the treatment of choice. • This model has rationale and elements in common with other prevention programs that are based on a public health orientation. • Such prevention programs consist of three essential components: education, skills training, and practice in applying skills.

5. Prevention • The Teams-Games-Tournament (TGT) model consists of the same components as other prevention programs, except for an additional component: It uses peers as parallel teachers. • The prevention approach to intervention has implications for the traditional role of the human services practitioner and for the timing of the intervention. • The prevention approach places major emphasis on the teaching and skills-building components of the intervention process.

6. Prevention • Practitioners do not take a passive role in the intervention process, but instead attempt to help clients learn how to exert control over their own behaviors and over the environments in which they live. • Professional knowledge, expertise, and understanding of human behavior theory and personality development are used by the practitioner in the conceptualization and implementation of intervention strategies.

7. Need for Prevention Programs • Deficit-ridden state and local governments are cutting back prevention programs in order to balance their budgets. • This proves to be cost-ineffective on every level. • One example: family planning services and teen pregnancy programs. • Savings in public medical costs alone are estimated to be $4.40 for each $1 spent in contraceptive services. (Forrest & Singh, l990)

8. Need • Almost 10 million women of reproductive age have no insurance, and more that 5 million women are insured under plans that do not provide, largely for financial reasons, maternity coverage. (U.S., GAO,1990) • The largely disorganized publicly funded family planning system we now have provides contraceptive services for about 4.5 million women, most of whom are at high risk for unplanned pregnancies. • Without these services there would be an estimated 1.2 million additional unintended pregnancies each year and over 500,000 additional births.

9. Need • Infant mortality rates (IMRs) would only be greater. • Federal and state governments spend approximately $400 million annually for contraceptive services. • They save approximately $1.8 billion on services that would have to be rendered to those women who would otherwise give birth. • These trends underscore the importance of supporting, rather than cutting, prevention and early prevention programs.

10. Social Problems:Teenage Pregnancy • The high incidence of teenage pregnancy is the result of a decrease in the average age of menses, combined with increasing sexual activity among adolescents. • Many health problems are affecting adolescents at younger ages. • The decline in age at first intercourse has produced increased rates of sexually transmitted diseases among adolescents.

11. Teenage Pregnancy • By the time they are 18 years old, 65% of boys and 51% of girls are sexually active. • Approximately 50% of American adolescents do not use contraceptives the first time they have intercourse. • Half of premarital pregnancies occur within the first 6 months after sexual initiation. • Each year 11% of adolescent women become pregnant, and 4% have an abortion.

12. Teen Pregnancy • Adolescents who become pregnant while in high school are more likely to drop out of school, become dependent on welfare, and become single parents. • Between 1950 and 1985 the nonmarital birth rate among adolescents younger than age 20 increased 300% for Whites and 16% for Blacks.

13. Teenage Pregnancy • Approximately 2.5 million adolescents have had an STD, and 1 in 4 sexually active adolescents will contract an STD before graduating from high school. • STD rates are substantially higher among Black adolescents.

14. Teenage Pregnancy • The National Research Council estimates that, for each year a first birth is delayed, a family’s income when the mother reaches 27 is increased by $500. • Every year a first birth is delayed (up to age 20) the chances of a woman and her family having an income below poverty level are reduced by about 22% • The Children’s Defense Fund reports that women who first give birth as teens have about half the lifetime earnings of women who first give birth in their twenties.

15. Teenage Pregnancy • The Center for Population Options determined that the federal government spent $21.6 billion in l989 on families begun by teen mothers. • Based on the assumption that families begun by a teen birth comprise 53% of the welfare-recipient population, they consume 53% of the funding of these programs (AFDC, Food stamps, Medicaid) • The CPO estimates that the families begun in 1989 by a teen birth will have cost the public treasury $6.4 billion by the year 2009.

16. HIV/AIDS • More than two thirds of adolescents with AIDS were infected through sexual contact with adults. • Although only 440 people with AIDS (fewer than 1%) are between ages 13 and 19, the prevalence of HIV infection among adolescents is a source of concern. • It takes an estimated 5 to 10 years for the HIV infection to result in AIDS; many young adults who have AIDS contracted the virus as adolescents.

17. HIV/AIDS • Approximately 20% of people identified as having AIDS are between ages 20 and 29 (AMA, 1991). • The United States spent about $10 billion on HIV-related activities in 1991. • Hellinger (1990) estimates the direct medical costs of AIDS in 1991 to have been $5.8 billion, with the cost of treating an HIV-infected person averaging $5,150 yearly and the cost of treating a patient with full-blown AIDS averaging $32,000 yearly.

18. HIV/AIDS • The Centers for Disease Control (CDC) estimates that over 500,000 persons in this country are HIV infected and do not know it. • The costs of HIV-related expenses are expected to continue rising until some type of cure or solution is found.

19. Substance Abuse • The United States has become a chemical culture. • The use and abuse of chemical substances exact an incalculable cost for substance abusers and non-abusers alike. • In 1987, it was estimated that 100,000 to 120,000 deaths are directly attributable to substance abuse, and another 120,000 to 150,000 deaths are substance abuse related.

20. Substance Abuse • Many adolescents experience confusion and turmoil as they strive to achieve autonomy. • Adolescents perceive taking psychoactive substances as on of their few pleasurable options. • The use and abuse of mood-altering chemical substances are now an integral part of growing into adulthood in the United States. • Morrison (1985) notes that two thirds of high school students use drugs and alcohol at least three times a week. • Additionally, 65% to 70% of junior high school students use drugs and alcohol two to three times weekly.

21. Substance Abuse • Long range consequences of teenage substance misuses include the failure to formulate goals for the future and stigmatization following an arrest while under the influence of drugs. • Patterns of substance abuse also have significant health consequences. • Yet more teenagers die in alcohol and drug related motor vehicle accidents than any disease.

22. Substance Abuse • One fourth of all alcohol and drug related motor vehicle fatalities involve males ages 16 and 19. • Tragically, drug overdoses also result in 88% of all adolescent suicides. • Drug related problems begun in adolescence, or earlier, mount to staggering proportions as young addicts or abusers age.

23. Substance Abuse • In 1989, the Justice Department estimated the social costs generated by each addict to have been about $200,000 per year. • Drug related criminal justice costs have since skyrocketed. • According to Rice and colleagues, 26% of our total policy protection expenditures can be attributed to drug related crime.

24. Substance Abuse • The total economic costs to the nation of alcohol misuse were estimated by Rice and colleagues to have bee $70.3 billion in 1985, a year in which 94,765 deaths were attributed to alcohol. • A National Institute on Drug Abuse study found that American firms spend at least 25% on substance abusing employees wages responding to their performance deficiencies. • The National Council on Compensation Insurance estimates that substance abuse cost American business $16 billion in worker’s compensation alone in 1987.

25. Substance Abuse • The total cost to society of drug abuse was $44.1 billion, whereas for alcohol it was $70.3 billion. • Core costs for drug abuse were $10.6 billion for 1989, during which 6,118 deaths were attributed to drugs. • Core costs for alcohol were $58.2 billion, yet alcohol attributed deaths numbered 94,765.

26. Smoking • Cigarette smoking is the single most preventable cause of death in the United States. • It is directly responsible for one in six deaths – 22% of all deaths among men and 11% of all deaths among women. • An estimated 30% of all cancer deaths, 87% of lung cancer deaths, 21% of deaths from coronary heart disease, 18% of stroke deaths, and 82% of deaths from chronic obstructive pulmonary disease are attributed to cigarette smoking.

27. Smoking • Americans spent a record breaking $44 billion on tobacco products in 1990 – $41.8 billion on cigarettes alone. • Warner estimated that nonsmokers pay 62% of the economic costs of cigarette smoking. • If that is true, the external costs of smoking in 1985 may have been as much as $22 billion in health care and as great as $38 billion in lost productivity.

28. Children at Risk for Abuse • From 1980 to 1986 the reported incidence of child abuse and neglect increased by 66% from 9.8 to 16.3 children per 1,000. • The National Clinical Evaluation Study described in Daro (1988) made the following findings: • Approximately 30% suffered chronic health problems. • Approximately 30% displayed cognitive or language disorders.

29. Children at Risk • Study (continue): • Approximately 22% had learning disorders requiring special education. • Approximately 50% had been disciplined at school for misconduct or poor attendance. • Approximately 50% suffered severe socioemotional problems such as low self-esteem, lack of trust, or low frustration tolerance. • Approximately 14% engaged in self-mutilative or self-destructive behavior.

30. Other Children At Risk • Five major studies of births in the United States, Canada, and Wales found that 21% to 30% of the incidence of low birth weight was due to maternal smoking. • An estimated 3.2% of pregnant women drink alcohol while pregnant, resulting in an estimated incidence of 59 fetal alcohol syndrome babies per 1,000 live births.

31. Other Children At Risk • Over 11% of the population admit to some cocaine use; 1.4% admit to using crack. • The National Association for Prenatal Addiction Research and Education estimates that 375,000 drug-exposed babies are born each year, most of whom have been exposed to cocaine. • The U.S. GAO estimates that 280,000 pregnant women were in need of drug treatment services in 1990. • Less than 11% received care even though $32 million for treatment was provided.

32. Racial Disparities • An examination and comparison of social indicators – rates of unemployment, delinquency, substance abuse, and teenage pregnancy - show that Blacks were relatively worse off in the 1990s than in the 1960s. • Blacks are 23% more likely than Whites to abstain from drinking.

33. Racial Disparities • Blacks experience far more social and medical problems associated with heavy drinking than do Whites. • The unexpected disparity in adverse consequences may perhaps be explained by the greater underreporting of drinking among Blacks, variations in drinking patterns, or racial differences in biological vulnerability to alcohol.

34. Racial Disparities • Even though American infant mortality rates (IMR) have fallen a great deal during the last century, the relative position has deteriorated dramatically. • In 1918, the United States ranked 6th out of 20 countries. • In 1986 the United States ranked 13th out of 20 countries. • In 1975, the total IMR stood at a historical low of 16.1 deaths per 1,000 live births. • The figure for White babies was 14.2; for Black babies it was 26.2.

35. Behavioral Social Work:A Means to a Solution • Behavioral social work involves the systematic application of intervention derived from learning theory and supported by empirical evidence to achieve behavior changes in clients. • The behavioral social worker must possess both theoretical knowledge and an empirical perspective regarding the nature of human behavior and the principles that influence behavioral change.

36. Behavioral Social Work • The work also must be capable of translating this knowledge into concrete behavioral operations for practical use in a variety of practice settings. • The behavioral social worker must possess a solid behavioral science knowledge base as well as a variety of behavioral skills. • Theory, practice, and evaluation are all part of one intervention process.

37. Knowledge Base • The central emphasis of behavioral social work is on employing empirically supported procedures that are aimed at the solution of the client’s difficulties. • The body of knowledge that the behavioral practitioner needs to possess in order to be an effective agent of change includes:

38. Knowledge Base • A thorough understanding of the scientifically derived theories of human learning as they relate to human behavior, which research shows are necessary conditions, but not sufficient in themselves, for therapeutic change. • The ability to make accurate behavioral assessments that include the specification of those conditions that are antecedent and consequential to the problem behaviors under consideration.

39. Knowledge Base • The ability to formulate behaviorally relevant and specific treatment goals. • The ability to implement effectively a treatment plan designed to modify those target behaviors identified by the clients as problematic. • The ability to evaluate objectively any treatment procedure and outcome and to formulate new treatment strategies when those that had been formulated originally have proven ineffective.

40. Assessment • An effective intervention addresses assessment prior to initiation of change. • Rapid assessment techniques have become increasingly popular with practitioners and agencies alike. • Social workers have begun to identify the utility of rapid assessment instruments to collect large quantities of and better quality data.

41. Assessment • Schwartz (1993) found that clients who were given rapid assessment instruments throughout treatment made more improvement on their goals, terminated from treatment less often, and were in general more satisfied with treatment. • These instruments are more efficient as well as more accurate.

42. Implementation of Change Strategy • Individual vs. group treatment: • The casework relationship is unlike most situations faced in daily interactions. • The group interaction more frequently typifies many kinds of daily interactions. • Services facilitating the development of behaviors that enable people to interact in groups are likely to better prepare them for participation in larger society.

43. Individual vs. Group Treatment • Groups provide a context where behaviors can be tested in a realistic atmosphere. • These theoretical rationales indicate that treating clients in groups should facilitate the acquisition of socially relevant behavior. • Group treatment is equally effective as individual service.

44. Individual vs. Group Treatment • In instances where an individual does not possess the necessary social behaviors to engage in group, a one to one treatment relationship may provide the best treatment context. • However, as soon as they develop the necessary social skills, therapeutic changes are likely to be further facilitated if they can be placed in a group.

45. Macrolevel Intervention • If a change agent decides that a client is exhibiting appropriate behaviors for his or her social context but that a treatment organization or institution is not providing adequate reinforcers for appropriate behaviors or that it is punishing appropriate behavior, the change agent must then decide to engage in organizational or institutional change.

46. Macrolevel Intervention • In social work practice, the primary focus has been on changing the individual. • Practitioners must restructure their thinking. • “Inappropriate” behavior exhibited by a client must be examined according to who defined it as inappropriate and where requisite interventions should take place.

47. Generalization and Maintenance of Behavior Change • Considerable study is needed to delineate those variables that facilitate the generalization and maintenance of behavior change. • These may include substituting naturally occurring reinforcers, training relatives or other individuals in the clients’ environment, gradually removing or fading the contingencies, varying the conditions of training, using different schedules of reinforcement, and using delayed reinforcement and self-control procedures.

48. Client Outcomes • The first requisite for the use of research in practice is the delineation of the possible outcomes for the client. • It is evident that professional and clients’ values, theoretical orientation, agency goals, sociopolitical factors, available resources, and practice context affect the chosen outcomes.

49. Specific Applications to Adolescents • Peers: • For teenagers, actions detrimental to health frequently occur in situations involving peers. • Although teenagers may understand health risks, this understanding is insufficient to counter the social significance of indulging. • Specific cognitive and behavioral skills are needed to resist external pressures and to successfully negotiate interpersonal encounters where pressure occurs.

50. Applications • Peers: • Adolescents often lack these skills, not because of individual pathology, but for developmental reasons. • Age brings increased opportunity to engage in previously unknown or prohibited activities. • Lack of experience and prior learning opportunities hamper youths’ abilities to deal with new situations and new behavioral requirements.