http://www.apa.org/journals/amp/amp549755.html When Interventions Harm: Peer Groups and Problem Behavior
Excerpts:
The Adolescent Transitions Program Study
Group counseling and guided group interaction produced a negative effect on delinquent and antisocial behavior (Berger, Crowley, Gold, Gray, & Arnold, 1975; Feldman, 1992; Gottfredson, 1987; O'Donnell, 1992).
In this article, we tested the hypothesis that high-risk young adolescents potentially escalate their problem behavior in the context of interventions delivered in peer groups. To examine this hypothesis, we first invoked studies on adolescent social development, indicating the processes that might account for problem behavior escalation.
Second, we reviewed two controlled intervention studies involving peer aggregation that produced negative short- and long-term effects on high-risk young adolescents. Finally, we discussed the developmental and intervention studies and proposed conditions that might increase the likelihood of negative effects with respect to underlying developmental processes. We also proposed directions for future intervention research to both accurately detect and understand iatrogenic effects associated with peer aggregation.
Iatrogenic- induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures.
To examine the relative efficacy of the different intervention conditions, we randomly assigned 119 high-risk youth (boys and girls) and their families to one of four intervention conditions: (a) parent focus only; (b) teen focus only; (c) both parent and teen focus; and (d) an attention placebo group, referred to as self-directed change, which included free access to videotapes and written materials. We recruited a quasi-experimental control group (n = 38) to evaluate the extent to which the self-directed intervention reduced problem behavior. Outcome analyses combined the self-directed and control groups for comparisons with the relative effects of the teen and parent focus groups. Dishion and Andrews (1995) compared the characteristics of the participants, as well as the outcomes for the two groups, and found them virtually equivalent.
We hypothesized that the optimal intervention would be the combined condition, involving both the parent and teen focus curriculums (Dishion et al., 1988). Consistent with this hypothesis, many of the short-term effects were quite positive. For example, both teen and parent focus participants showed more curriculum-specific knowledge following the intervention (Dishion, Andrews, Kavanagh, & Soberman, 1996). More important, both interventions resulted in statistically reliable reductions in observed negative family interactions (Dishion & Andrews, 1995). Parent reports of family conflict suggested that the teen and parent focus cognitive?behavioral intervention considerably reduced family tension and conflict.
Unfortunately, more complete long-term analysis revealed that negative effects were associated with the teen focus curriculum. Three months after random assignment, we noted an increase in tobacco use among the teen focus participants. One year following the families' involvement in the ATP study, increases in tobacco use and teacher report of externalizing behavior were found to be reliably higher for the teen focus groups, compared with problem behavior within the control conditions (Dishion & Andrews, 1995). The effect sizes were strong enough to undermine the short-term positive gains of the parent focus intervention (Dishion & Andrews, 1995; Dishion, Andrews, et al., 1996). The combined parent and teen focus intervention programs did not reduce risk for substance use and delinquency, as hypothesized.
Three-year follow-up assessments suggest that the iatrogenic effects of the teen focus conditions persisted for tobacco use and delinquency (Poulin, Dishion, & Burraston, in press). As shown in Figure 2, random assignment to teen focus, regardless of the accompanying intervention with parents, was associated with long-term increases in tobacco use.
A reasonable argument might be that the long-term effects are attributable to changes in youth-reporting strategies, representing an Intervention × Assessment interaction (Campbell & Stanley, 1963). Contrary to this hypothesis were the results of the analysis on the Delinquency scale of the teacher version of the Child Behavior Checklist (Achenbach, 1991). During the intervention study, teachers were unaware of each student's intervention condition. They knew even less of the ATP study in later years of follow-up. As shown in Figure 3, teachers reported higher levels of delinquent behavior in youth randomly assigned to teen focus, compared with controls; these levels persisted over the three-year follow-up period.
The Cambridge?Somerville Youth Study Evaluation
used a comprehensive approach to crime prevention, based on knowledge that high-risk children lacked affectionate guidance (Healy & Bronner, 1936; Powers & Witmer, 1951).
Treatment began when boys were, on average, 10.5 years old and terminated shortly after they reached the age of 16. Although the intensity of treatment varied, boys were visited an average of twice a month in their homes. Counselors encouraged their participation in local community groups and took the boys to sporting events, taught many of them how to drive, helped them obtain jobs, and served their families in a variety of ways (including help with finding employment, assisting in the care of younger children, counseling, and providing transportation).
An evaluation shortly after the program ended failed to turn up differences between the treated and untreated boys (Powers & Witmer, 1951). Many suggested that judgment be delayed until the boys fully matured. When the CSYS participants reached middle age, an intensive effort was made to find them and assess the effects of their treatment; that search resulted in 98% retention by 1979. Vital statistics, the courts, mental hospitals, and alcohol treatment centers provided objective evidence by which to evaluate effects of the program. Distressingly, as reported earlier, the treatment program apparently had harmful effects (McCord, 1978, 1981).
Two analyses indicated that the iatrogenic effects came from the treatment program. First, boys who received the most attention over the longest period of time were the most likely to have iatrogenic effects. A dose?response analysis showed those in treatment longer, and those who received more intense treatment, were most likely to have turned out worse than their matched controls (McCord, 1990). Second, the iatrogenic results occurred only in the cooperative families. Among those, 27 pairs of treatment boys turned out better, but 52 pairs turned out worse. Among the pairs in which the treatment family was uncooperative, the control and treatment boys were equally likely to turn out badly (McCord, 1992).
Attempts failed to find subgroups for whom treatment had been beneficial. Those who started treatment at very early ages were not less likely to have bad outcomes than their matched controls. Nor was there evidence to show that some particular variation of treatment had been effective. Moreover, when comparisons were restricted to those with whom a counselor had particularly good rapport, or those whom the staff believed they had helped most, the objective evidence failed to show the program had been beneficial (see McCord, 1981, 1990, for details).
The comparison of outcomes among matched pairs of boys shows that although none of the groups benefited from treatment, most of the damaging effects of the CSYS program appeared among the boys who had been sent to summer camp more than once (see Figure 4) and who turned out considerably worse than their matched mates. Among these pairs, the risk ratio for bad outcome was 10:1. In 20 pairs, only the treatment boys had bad outcomes, whereas the control boys had bad outcomes only in two pairs.
Both processes suggest that repetition of contact within the peer-group intervention would create the iatrogenic effect observed in these two intervention studies, especially among those youth likely to engage in deviant talk and behavior primarily in the company of peers.
We hypothesize that the reinforcement processes within the peer groups are quite subtle and potentially powerful. For example, Buehler, Patterson, and Furniss (1966) found that within institutional settings, peers provided a rate of reinforcement of 9-to-1, compared with adult staff, suggesting that the density of reinforcement from peers can be so high it seriously undermines adult guidance.
Research by Chamberlain and colleagues revealed that mobilizing adult caregiving is a critical and viable intervention target for even the most severe adolescent delinquent (Chamberlain & Moore, 1998; Chamberlain & Reid, 1998). Her research compared a treatment foster care model with group home treatment, finding that the former resulted in reductions in deviant peer contact and subsequent self-reported and court-documented delinquency, compared with group home placement.
Moreover, interventions with high-risk parents have shown results in improved parenting, concomitant reductions in child and adolescent problem behavior (Dishion et al., 1995; Dishion, Spracklen, et al., 1996; Webster-Stratton, 1990), and improvement in academic skills (Forgatch & DeGarmo, in press). Therefore, the cost-effectiveness of group interventions is retained if focus is on the parents and aggregating young adolescents is avoided.
To really understand the impact of interventions with adolescents, researchers will have to assess a variety of short- and long-term outcomes (Kelly, 1988) addressing expected intervention outcomes (e.g., targeted skills) with real-world outcomes (e.g., behavior in the natural environment). The scientific and professional community must be open to the possibility that intentions to help may inadvertently lead to unintentional harm.
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
This is a settled topic. This has been proven to be damaging for decades.
The PPC treatment modality leads directly to iatrogenic delinquency. It really couldn't be any clearer.
I have a very strong background in juvenile delinquency as my mentor is Dr. Herman Schwendinger (and his wife, Julia, to a lesser extent), perhaps the most prolific researcher of modern juvenile delinquency, and his conclusions and teachings mirror those of this study.
