SOCW 6002 FSU Ethical Issues and Dilemmas in Caring for Children and Adolescents Paper

In a4-page APA format paper include the following:

• Briefly describe the illness you selected.
• Explain an ethical issue involving a child or adolescent in the context of the illness. Be sure to explain all sides of the ethical dilemma. (ex child social and physical development, psychological factor, family etc.)
• Explain your ethical responsibilities as a social worker (medical social worker) in adherence with the professional ethical standards applicable to the clinical situation. Be sure to justify your response citing the NASW Code of Ethics

Adverse Childhood Experiences and Resilience:
Addressing the Unique Needs of Adolescents
Samira Soleimanpour, PhD; Sara Geierstanger, MPH; Claire D. Brindis, DrPH
From the Philip R. Lee Institute for Health Policy Studies (Dr Soleimanpour, Ms Geierstanger, and Dr Brindis), and Adolescent and Young
Adult Health National Resource Center (Dr Brindis), University of California, San Francisco, Calif
Conflict of Interest: The authors declare that they have no conflict of interest.
Address correspondence to Samira Soleimanpour, PhD, 3333 California St, Suite 265, San Francisco, CA 94143-0936 (e-mail: samira.
soleimanpour@ucsf.edu).
ABSTRACT
Adolescents exposed to adverse childhood experiences (ACEs)
have unique developmental needs that must be addressed by the
health, education, and social welfare systems that serve them.
Nationwide, over half of adolescents have reportedly been
exposed to ACEs. This exposure can have detrimental effects,
including increased risk for learning and behavioral issues
and suicidal ideation. In response, clinical and community systems need to carefully plan and coordinate services to support
adolescents who have been exposed to ACEs, with a particular
focus on special populations. We discuss how adolescents’
ADVERSE
CHILDHOOD EXPERIENCES (ACEs) are
increasingly a focus of both research and interventions
nationwide, given emerging evidence of their high prevalence and lifelong health impacts. To date, much of the
ACEs literature has focused on children and adults. Greater
attention should be paid to the distinct developmental
needs of adolescents and how the systems that serve
them can more adequately respond.
Distinct from both childhood and adulthood, adolescence is a unique developmental stage of rapid growth
during which physiologic, cognitive, social, and
emotional changes occur simultaneously. During this
time (ages 11 to 21 years), adolescents experience physical and sexual maturation, develop more abstract and
long-term thinking, and engage in risk-taking behaviors
as they establish their independence. Adolescents who
have experienced ACEs may be less able to successfully
navigate this transformational stage as a result of the
damaging effects of traumatic experiences on their
emotional and cognitive development and/or lack of or
limited positive supports.
A large body of research has demonstrated that investments in early childhood can yield significant social and
economic returns in adulthood and that this developmental
stage should be prioritized for investments, particularly for
disadvantaged youth.1,2 However, this research also
supports the notion that to maximize returns, there is a
concurrent need to invest resources to address the needs
ACADEMIC PEDIATRICS
Copyright ª 2017 by Academic Pediatric Association
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needs can be met, including considering confidentiality concerns and emerging independence; tailoring and testing
screening tools for specific use with adolescents; identifying
effective multipronged and cross-system trauma-informed interventions; and advocating for improved policies.
KEYWORDS: adolescent health policy; adolescents; adverse
childhood experiences; resilience; trauma
ACADEMIC PEDIATRICS 2017;17:S108–S114
of adolescents, particularly for those who may not have
received needed supports in early childhood and/or who
continue to experience ACEs into adolescence.
Thus, adolescence represents a key window of opportunity to ameliorate the short- and longer-term impacts of
trauma and positively alter the life course trajectory.
High rates of trauma exposure have led to a pressing
need to identify youth who have been exposed; recognize
the varied ways in which youth respond to these experiences; identify effective strategies to provide traumainformed care; and develop policy recommendations to
prevent and respond to the impacts of ACEs.
There are many aspects of ACEs that affect adolescent
health and warrant in-depth exploration. Here we provide
an overview of these issues, with the hope that it helps
identify areas for further analysis and critique in the
literature.
PREVALENCE AND IMPACTS OF ACES IN
ADOLESCENCE
Researchers have defined ACEs as including physical
or emotional abuse or neglect, sexual abuse, domestic
violence, substance abuse or mental illness in the home,
parental separation or divorce, having an incarcerated
household member, and not being raised by both biological parents.3 Recent research indicates that over half
(54%) of all adolescents aged 12 to 17 years in the
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September–October 2017
ACADEMIC PEDIATRICS
United States have been exposed to at least one of these
experiences, and over one-quarter (28%) experienced 2 or
more.4 Children living in homes with lower household incomes or in less safe and supportive neighborhoods, as
well as those who qualified as having special health
care needs, were more likely to experience ACEs.5
Furthermore, certain subgroups of adolescents face
heightened risks, including youth who are lesbian, gay,
bisexual, transgender, or questioning (LGBTQ) and those
who are incarcerated or involved in the juvenile justice
system.5–7 Despite the high prevalence, the majority of
adolescents with trauma exposure do not receive needed
health services that are critical to identifying and
addressing these concerns.8
The effects of trauma during childhood and adolescence have impacts on adolescent health and educational
status, including a greater likelihood of repeating a grade
in school, lower resilience, increased risk for learning and
behavioral issues, suicidal ideation, and early initiation of
sexual activity and pregnancy.5,8–10 In fact, there is a
much higher prevalence of these negative impacts
among adolescents aged 12 to 17 after experiencing
more than one ACE. With 3 or more ACEs, nearly half
(48%) of youth experience low engagement in school,
44% cannot stay calm and controlled, and 41%
demonstrate high externalizing behaviors.11 Moreover,
exposure to trauma in childhood and adolescence can
lead to negative consequences in adulthood, including
chronic illness and decreased productivity,12,13
especially when they are experienced cumulatively or
chronically.4,5,14–17
Despite the negative impacts of ACEs, literature is
emerging on the countereffects of resilience and protective factors. Resilience theories focus on strengths
that individuals possess internally, such as coping
skills, and externally, such as family and community
supports, rather than risks and deficits, and how these
strengths can help them overcome risk exposure or traumatic experiences.17–20 Positive individual-, family-,
and community-level factors, including high levels of
family functioning and parental engagement, are associated with favorable outcomes for children and
adolescents who have been exposed to ACEs.21–23
Family functioning in particular is a protective
factor against poverty, neighborhood violence, poor
parental relationships, and adolescent mental health
concerns.24–26 One national study found that resilience,
defined as “staying calm and in control when faced
with a challenge,” lessened the impacts of ACEs on
grade repetition and poor school engagement.5 Another
study examining similar data found that many factors
mediate the relationship between increasing ACEs exposure and negative outcomes, including residing in a safe
neighborhood, attending a safe school, and parental
monitoring of friends and activities. Understanding,
identifying, and nurturing protective home, school, and
community elements may help diminish the overall
impact of youth’s exposure to ACEs.4
ACES AND RESILIENCE
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RESPONDING TO THE UNIQUE NEEDS OF
ADOLESCENTS
Adolescence represents a unique period for major social,
psychological, and physical development, and a time in
which youth frequently have unmet physical and mental
health needs. For example, 20% of younger adolescents
(10–15 years) and 27% of older adolescents (16–17 years)
did not receive annual well-child visits, and 64% of adolescents with mental disorders did not receive services to
address their illnesses.27–29 Furthermore, those from
disadvantaged backgrounds are at the highest risk of not
having regular health maintenance visits or receiving
needed mental health care.27,29–31 Many adolescents also
tend to engage in health behaviors that place them at risk
for the leading causes of morbidity and mortality.32 As adolescents begin to gain greater independence and assume
individual responsibility for daily health habits, develop
new social relationships, and individuate from their parents, these changes bring new opportunities and challenges
for improving health and preventing disease. In response,
clinical and community health, educational, and social
welfare systems need to carefully plan and coordinate services to support adolescents who have been exposed to
ACEs, with a particular lens on special populations—for
example, youth who have been in the foster care system;
those who have been incarcerated, homeless, or substance
dependent; and/or LGBTQ youth.
CONFIDENTIALITY CONCERNS
Pediatric care for youth aged 0 to 21 typically includes a
strong focus on parental involvement. However, patient
privacy is vital to assuring patient-centered services during
adolescence, when the complexity of medical and behavioral health needs increase. Professional guidelines recommend that health care providers spend time alone with their
adolescent patients beginning in early adolescence (11 to
14 years).33 These encounters help adolescents learn how
to manage their health with greater independence—for
example, by learning how to manage a chronic health condition, avoid health-damaging behaviors, and navigate successful relationships with health care providers. However,
one study of national data found that only 34% of adolescents had time alone with their providers, with younger
girls and Hispanics youths of all ages being less likely
than their peers to have time alone.34 Adolescents who
have experienced trauma are particularly in need of time
alone with providers, as it provides the opportunity to begin
to develop trusting relationships to safely disclose their
experiences.
In addition to time alone with providers, adolescents
need assurances that sensitive information they share will
be confidential. In fact, adolescents who engage in highrisk health behaviors are likely to cite confidentiality concerns as a reason for foregoing health care.35 There are
confidential care laws that allow adolescents to consent
to their own health care without parental notification.
These laws differ by state, but they appropriately allow
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for greater independence in the adolescent–provider relationship, particularly in the delivery of sensitive services,
such as reproductive and mental health care.36
Empirical research has shown that adolescents are more
likely to disclose sensitive information when providers
assure confidentiality.37 A recent study also found that
the use of motivational interviewing, to facilitate intrinsic
motivation within the client, and the provision of confidentiality assurances increased the likelihood of providers
spending time alone with their adolescent patients.38
SCREENING AND IDENTIFICATION
Despite high prevalence rates of trauma and the
increasing awareness of the importance of this topic,
screening for traumatic experiences in adolescent health
care settings has been inconsistent. For example, one study
of female adolescents seeking health care in urban settings
found that while 40% of clinic users had experienced intimate partner violence, less than one-third (30%) reported
ever being screened for intimate partner violence in a clinical setting.39
Low screening rates are partly attributed to a lack of
appropriate assessment tools. Few instruments have been
sufficiently validated for use with adolescents, and few
examine trauma symptoms beyond posttraumatic stress
disorder.40 Researchers have found traditional diagnostic
categories of trauma exposure, including posttraumatic
stress disorder, limiting in that individuals are diagnosed
on the basis of symptoms triggered by a specific event,
and they thus do not capture exposure to multiple adverse
experiences or events that may collectively warrant diagnosis. As a result, newer diagnostic categories, such as
“developmental trauma disorder” and “complex trauma,”
have been created to address these limitations. However,
corresponding assessment tools have not yet been developed.40 Existing validated tools for use with adolescents
are also lengthy and can be challenging to administer during brief clinical visits where many issues, including sexual
activity, mental health, substance use, and school experiences, need to be assessed.
Although in-depth information or critical analysis of
available screening tools that assess for ACEs is beyond
our scope here, current tools used in adolescent clinical
practice include the Center for Youth Wellness (CYW)
ACE–Questionnaire Child, Teen, & Teen Self-Report,
and the Yale–Vermont Adversity in Childhood Scale
(Y-VACS).41 The National Child Traumatic Stress
Network also provides a comprehensive list of validated
tools to assess various aspects of trauma exposure.42
(See also Bethell et al43 in this supplement for further
detail on screening tools.)
Low screening rates also reflect challenges within the
health care delivery system, particularly limited awareness
of ACEs,44 lack of consensus and formal training on
screening tools, and lack of formal training of providers
in the prevalence and incidence of trauma or how to implement trauma-informed care.45,46 Providers without ready
access to behavioral health services may feel hesitant to
ACADEMIC PEDIATRICS
uncover trauma without having an adequate system in
place with which they can respond, such as through
referrals to follow-up care. Moreover, screenings are often
not conducted because providers do not have either the
time or the reimbursement incentive to screen or address
many of these issues.
Approaches to screening also present opportunities and
challenges. In particular, there is some debate as to whether
all youth should be screened during initial encounters
with service providers (universal screening) or if select
youth should be screened during follow-up visits after
patient–provider rapport has been established. Advantages
of universal screenings are that they are brief, are less
resource intensive, and can quickly identify youth who
are at risk and who require additional, more intensive
screening and follow-up. Additionally, providers can
immediately understand each youth’s trauma history and
target subsequent encounters and interventions accordingly. However, the screening process itself can potentially
retraumatize a patient and hinder progress if there are not
appropriate interventions or referrals in place,47 which
would instead support screenings at follow-up visits after
initial trust has been established.
Furthermore, emerging research demonstrates that current screenings for ACEs should be expanded to include
other events that can impact youth’s health and development, such as economic hardship, family relationships,
community stressors, peer relationships, discrimination,
and school experiences,48 as well as resilience and protective factors. Clinical and community programs should
implement strategies for the early identification of at-risk
youth through comprehensive assessments beyond the
traditional ACEs while balancing the time required for
these comprehensive assessments. A promising area is
the inclusion of Bright Futures recommendations of
screening for mental health disorders and emotional and
behavioral problems as part of an annual checkup
(Table 1).49 This is a requirement of the Affordable Care
Act and is reimbursable.50 Under the act, which requires
the incorporation of Bright Futures recommendations, providers have been able to maximize the opportunity for
screening, thus resolving traditional barriers of lack of
reimbursement for screening and follow-up.
INTEGRATED SYSTEMS OF CARE
Once identifying youth as having been exposed to
trauma and suffering from the consequences, there must
be a strong network of coordinated care to provide appropriate referrals to individual, group, and/or family services.
These should include home-based supports for youth and
their families, as well as academic support and school supports for situations where students might experience triggers, situations, or stimuli that bring up memories of
traumatic experiences. Mental health and other services,
such as medical, education, and juvenile justice, should
be integrated to promote coordination of care and efficient
use of resources. (See also Brown et al51 and Vu et al52 in
this supplement.) Not all professionals who work with
ACADEMIC PEDIATRICS
ACES AND RESILIENCE
S111
Table 1. Recommendations for Annual Adolescent (11–19 Years) Checkups Related to Adverse Childhood Experiences (ACEs) and Resilience33,50
Adolescent Annual Check-up Components
All adolescents and parent/guardians should be informed about confidentiality and the following components of the visit should be conducted with
parents present and/or with the adolescent alone as appropriate:
1. Health history, including changes in physical or emotional health status warranting further assessment
2. Physical examination, immunizations, and screenings
3. Observations of parent-youth interaction and youth engagement in health decisions
4. Screening/discussion of the following priority topics related to ACEs/resilience:
 Emotional well-being: coping; moods, emotions, and mental health; resilience/protective factors
 Violence and injury prevention: domestic violence, intimate partner violence, community violence
 Social and academic confidence: connectedness with family, peers, and community; interpersonal relationships; school performance
adolescents need to be specialists in trauma, but they
should be trained to be able to identify adolescents in
need and know how to appropriately refer them to trauma
services. While each sector needs to focus on the outcomes
that it is designed to influence, together they can achieve a
greater overall impact through their complementary approaches and support.53 It is also important that adolescent
perspectives be brought into the development of traumainfused health services.54
Integration and coordination are critical, yet significant
challenges remain in practice. One of the largest barriers
is information sharing across sectors. For example, the
Health Insurance Portability and Accountability Act provides safeguards for protecting individuals’ personal health
information, which can limit providers’ ability to share
health information about mutual clients across agencies
to better coordinate care. However, there are exceptions
to the rule that allow sharing information for the purpose
of treatment. Furthermore, written authorizations from patients and their parents can be obtained to share information
with entities outside the health care system, such as school
mental health providers.55 Business associate agreements
that clearly outline how sensitive information will be
handled between agencies can also be implemented;
several have been developed and are available through
the US Department of Health and Human Services.
EVIDENCE-BASED INTERVENTIONS
Developmentally and culturally appropriate health services are instrumental in mitigating the short- and
longer-term risks of ACEs. Evidence is emerging about
the effectiveness of clinical treatments to intervene with
children who have experienced trauma and adversity. The
National Child Traumatic Stress Network recommends a
variety of strategies and tested interventions for working
with specific age populations.56 In particular, TraumaFocused Cognitive–Behavioral Therapy has an extensive
evidence base documenting its effectiveness in the treatment of trauma.57,58 This approach uses individual and
group cognitive–behavioral therapy to address the
multiple domains of trauma and to teach youth skills in
how to regulate their behavior, process the trauma, and
improve their sense of safety and trust.
Schools are also uniquely positioned to support adolescents who have been exposed to trauma or violence given
the amount of time youth spend there. According to a
national survey, nearly all schools nationwide (97%)
reported having at least one staff member whose responsibilities included providing mental health services to students; most commonly these are school counselors,
nurses, school psychologists, and social workers.59 Nationwide, there have also been several initiatives to create
trauma-informed schools. These efforts focus on the use
of multitiered interventions to address the varying needs
of youth exposed to trauma and violence.60 These strategies can be tailored to the degree of trauma individual students are exposed to; in addition, schools are uniquely
positioned to build resiliency and strength among young
people throughout the school population. An intervention
designed specifically for use in schools is Cognitive–
Behavioral Intervention for Trauma in Schools (CBITS).61
CBITS, which is founded on cognitive–behavioral therapy,
provides mental health screening and brief therapy sessions to help youth reduce trauma-related symptoms and
promote coping skills. CBITS is delivered through 10
weekly group sessions led by a school-based mental health
professional, such as a school psychologist or social
worker, with groups of 6 to 8 participating youth.62 CBITS
has been shown to lower the negative impacts of trauma
exposure, including depression, psychosocial dysfunction,
and academic functioning, particularly among diverse,
low-income students.63
Another emerging approach to address the impacts of
ACEs is the use of mindfulness interventions in school
and community settings. These interventions focus on
increasing individuals’ awareness of current experiences
and mental states while minimizing thoughts of past or potential future stressful experiences. Mindfulness interventions, which include yoga and meditation, have been
found to increase youth resilience and self-regulation of
stress, emotions, and behavior.64–67
The federal government took an important step toward
reinforcing trauma-informed approaches in schools
through the Every Student Succeeds Act (ESSA), signed
by President Barack Obama in December 2015.68 This
bipartisan measure reauthorized the United States’ national education law. Among other strategies, the ESSA
provides funding for school-based mental health services
and evidence-based, trauma-informed programming
(Table 2).
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SOLEIMANPOUR ET AL
FUTURE PRACTICE, POLICY, AND RESEARCH
RECOMMENDATIONS
The field of adolescent health care is in a nascent phase
in understanding how to screen and provide services for adolescents with ACEs. In many regards, the focus on ACEs
raises the challenge of an overall dearth of available pediatric and adolescent mental health professionals
throughout the system. To overcome these issues and a
number of gaps, several strategies are needed.
First, given the lack of mental health providers, policies
are needed and funding allocated to train and build the capacity of health care providers to assess trauma and provide
trauma-informed care with a focus on strengths and
fostering resilience.69 Curricula that address trauma
informed practices, including patient-centered, culturally
competent, and emotionally supportive care, should be
embedded into primary care and adolescent health provider
training programs. Educators and social services providers
should also be trained in trauma-informed practices, such
as providing safe spaces in schools for youth to calm
down after experiencing triggers or stressful situations,
not taking students’ behaviors personally or reacting with
punitive or stressful responses, and offering caring, supportive words, which can have immense impacts on traumatized youth.
Second, confidential care and time alone with providers
must be emphasized as well, possibly through standardized
training to ensure that providers feel comfortable speaking
to parents about the importance of nurturing their children’s autonomy, as well as education regarding the confidentiality laws that apply to adolescent health care.
Effective coordination of care between health care, school,
and community services is also needed. Policies that allow
for information sharing across sectors are critical to this
care coordination as well.
Third, improved screening tools designed specifically
for adolescents that are rigorously tested and that are not
burdensome in clinical or school-based settings are needed.
These validated tools can then be recommended as part of
clinical guidelines, similar to Bright Futures’ recent addition of suggested screening tools for adolescents’ sub-
ACADEMIC PEDIATRICS
stance use and depression to their preventive care
guidelines.49 Mainstreaming screening and traumainfused care into existing policies, programs, and practices
assures that these efforts are not merely an extra add-on but
rather are recognized as core to evidence-based programs
and their funding supports. Screenings should only be conducted after ensuring that services or referral sources are in
place to appropriately address the unique needs of youth
who are identified as needing any level of intervention.
This requires appropriate capacity and training among professionals and nonprofessionals who interact with youth,
and appropriate community referrals as necessary.
Fourth, those working in health and education settings
are all too familiar with the challenge of treating adolescents, only to send them back to the environments in
which they are experiencing trauma, which can significantly hinder any progress. It is critical that interventions are identified that can effectively impact the
roots of adolescents’ adverse experiences and address
them in relationship to their family members who may
also have been be exposed to ACEs. Interventions
should also be coordinated across sectors, including education, health, and social services. Furthermore, these
interventions should address health disparities and the
social determinants of health that coincide with ACEs,
including economic instability, limited education, and
unsafe home and community environments.
Fifth, evidence-based interventions in school, health
care, and work settings need to be expanded. Interventions
should also be tailored to appropriately serve adolescents
who may have greater needs as a result of experiencing
multiple ACEs without the protective role of supportive
families, schools, and communities, such as foster
care, LGBTQ, runaway or homeless, and juvenile justice
system–involved youth.
Finally, there is a need for expanded research on how
ACEs affect adolescents, either the trauma experienced
during childhood, which now impacts risk-taking behaviors during adolescence, or accumulated or new trauma
that occurs during the adolescent years, including any of
the aforementioned ACEs, as well as intimate partner
violence in dating relationships and other issues that arise
Table 2. Brief Overview of the Every Student Succeeds Act (ESSA) and Provisions to Support Youth Exposed to Adverse Childhood Experiences68
ESSA is the primary statute governing the federal government’s role in K–12 education and was signed by President Barack Obama in December
2015. This measure reauthorizes the Elementary and Secondary Education Act (ESEA) that was first passed during President Lyndon
Johnson’s administration, which was overhauled in 2001 by President George W. Bush’s administration as the No Child Left Behind Act. The
ESSA includes many provisions to ensure student success, including ensuring access to equitable education for all students; supporting locally
developed, evidence-based interventions; increasing access to high-quality preschool; targeting resources to students in schools with the
highest needs; and holding states accountable to supporting every child to be career or college ready.
The ESSA also has several provisions that support trauma-informed practices, including but not limited to providing funding for activities and
programs that support the following:
 Expansion of school-based mental health services.
 Training of school personnel to understand how trauma affects students and when to refer them for services, as well as in “effective and traumainformed practices in classroom management.”
 Reduction of exclusionary discipline practices and promotion of positive behavioral supports and interventions.
For more information, see http://www2.ed.gov/policy/elsec/leg/essa/essafaqstransition62916.pdf.
ACADEMIC PEDIATRICS
in adolescence. Perhaps most importantly, additional
research is needed on which interventions can best respond
to the unique needs of adolescents, taking into account
family dynamics, confidentiality, and community contexts,
as well as the specific risk behavior profile of adolescents.
Moreover, it will be important to monitor and evaluate implementation of ESSA and similar initiatives on the state
and local levels, including whether they remain in place
with the change in the presidential administration in 2017.
Without investments to identify and treat the impacts
of ACEs in adolescence, there can be tremendous costs
at the individual and societal level in future health and
productivity. Together, and through the development of
multipronged approaches, we have the ability not only
to impact adolescence as a critical phase of development
but to also reduce the impact of childhood trauma on the
life course as adolescents successfully transition into
adulthood.
ACKNOWLEDGMENTS
Financial disclosure: Publication of this article was supported by the
Promoting Early and Lifelong Health: From the Challenge of Adverse
Childhood Experiences (ACEs) to the Promise of Resilience and
Achieving Child Wellbeing project, a partnership between the Child and
Adolescent Health Measurement Initiative (CAHMI) and AcademyHealth, with support from the Robert Wood Johnson Foundation
(#72512).
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J Youth Adolescence (2012) 41:98–104
DOI 10.1007/s10964-011-9677-z
EDITORIAL
Invited Commentary: Childhood and Adolescent Obesity:
Psychological and Behavioral Issues in Weight Loss Treatment
David B. Sarwer • Rebecca J. Dilks
Received: 5 May 2011 / Accepted: 11 May 2011 / Published online: 31 May 2011
Ó Springer Science+Business Media, LLC 2011
Abstract The prevalence of childhood and adolescent
obesity has tripled in the past three decades. This increase
has been accompanied by a dramatic rise in obesity-related
health complications among American youth. Thus, many
obese youth are now experiencing illnesses that will
threaten their life expectancy in the absence of significant
weight loss. Despite these concerns, a relatively modest
body of research has focused on the treatment of adolescent
obesity. Results from trials investigating the efficacy of
behavioral and pharmacological treatments, like studies of
these interventions with adults, suggest that individuals
typically lose 5–10% of their initial weight. Unfortunately,
weight regain is common. Given the increase in the number
of obese adolescents, coupled with the modest results from
more conservative treatment approaches, it is not surprising
that bariatric surgery for adolescents who suffer from
extreme obesity has grown in popularity. The weight losses
after surgery are impressive and many adolescents, like
adults, experience significant improvements in their physical and mental health postoperatively. However, only a
small fraction of adolescents and adults who are heavy
enough for bariatric surgery present for surgical treatment.
Among those who undergo surgery, a significant minority
appear to struggle with a number of behavioral and psychosocial issues that threaten their lifelong success. With
all of this in mind, the current obesity problem in the
United States and other Westernized countries likely will
present a significant challenge to both current and future
D. B. Sarwer (&)
R. J. Dilks
Center for Weight and Eating Disorders,
University of Pennsylvania School of Medicine,
3535 Market St., Suite 3121, Philadelphia, PA 19104-3309, USA
e-mail: dsarwer@mail.med.upenn.edu
123
medical and mental health professionals who work with
adolescents and young adults.
The Childhood and Adolescent Obesity Problem
Obesity is a growing problem among America’s youth. The
rate of obesity or overweight ([95th percentile for age and
gender) has doubled among children and tripled among
adolescents over the last 20 years (Ogden et al. 2002). The
most recent data suggests that 31% of children in the United
States are currently overweight or obese (Ogden et al. 2010),
which translates into approximately 5 million children.
Furthermore, recent estimates suggest that 4% of American
children and adolescents are above the 99th percentile and,
thus, are extremely obese (Freedman et al. 2007). This
percentage is larger than the number of American youth
affected by cancer, cystic fibrosis, HIV and type I diabetes
mellitus combined (Freedman et al. 2007).
Instead of using the term ‘‘obesity’’ with children and
adolescents, several authorities recommend using the
Centers for Disease Control’s (CDC) BMI tables
(Kuczmarski et al. 2002). The CDC guidelines do not label
individuals as ‘‘obese’’. Instead, ‘‘at risk of overweight’’ is
used to describe youth between the 85th and 94th BMI
percentile and ‘‘overweight’’ is used for those above the
95th percentile (Dietz and Bellizzi 1999; Kuczmarski et al.
2002). By later adolescence, the 95th percentile approaches
the definition of adult obesity, &30 kg/m2 (Cole et al.
2000). Generally, the term ‘‘obesity’’ is only used for the
problem at the population level and for individual children
when adiposity has been confirmed by another measure in
addition to BMI (Speiser et al. 2005).
A particularly alarming trend suggests that the heaviest
youth are becoming heavier, thus placing more individuals
J Youth Adolescence (2012) 41:98–104
at greater risk for more immediate and serious weightrelated health problems. Overweight and obesity are
associated with insulin resistance, type II diabetes mellitus,
cardiovascular risk, menstrual irregularities, obstructive
sleep apnea, non-alcoholic fatty liver disease, and psychosocial problems in children and adolescents (Daniels
et al. 2005; Zeller et al. 2006). Adolescent obesity is known
to increase the rate of atherosclerosis, type II diabetes
mellitus, coronary heart disease, hip fractures, and gout in
adulthood. An investigation from the Nurses’ Health Study
found that obese adolescents had an almost 3-fold increase
in premature deaths (van Dam et al. 2006). The social
impact of obesity, especially on females, is staggering. As
obese female adolescents age, they are likely to suffer
extreme social consequences from obesity, including
achieving less educational status, earning less money,
being more likely to live in poverty, and being less likely to
marry (Gortmaker et al. 1993).
These physical and psychological issues recently have
led researchers to begin to study the efficacy of neighborhood and school-based obesity prevention programs (e.g.,
Foster et al. 2008). The goal of these programs is to
increase physical activity, decrease sedentary behavior and/
or reduce caloric intake. These approaches involve policies
to alter the social, regulatory or physical environments of
children and adolescents to promote the engagement of
healthy behaviors, even if the child is not aware that they
are adopting these behaviors (Robinson and Sirard 2005).
By starting early, the goal is to avoid excess weight gain as
the children go through adolescence and into adulthood
(Caballero 2004).
Although these programs may be shown to have some
impact, it is unlikely that these will stop, let alone reverse,
the obesity epidemic (Boutelle et al. 2011). Thus, most
researchers and clinicians remain focused on the issue of
treatment. Below, we will provide a review of the treatment
of childhood and adolescent obesity. We begin with an
overview of more conservative treatment approaches, such
as behavioral modification and pharmacotherapy. The
limited efficacy and durability of these approaches has led
to interest in the surgical treatment of obese adolescents.
Thus, the commentary concludes with a discussion of
recent and ongoing research on the use of bariatric surgery
for obese adolescents.
Behavioral Modification and Pharmacotherapy
for Adolescent Obesity
The treatment of childhood and adolescent obesity, as
compared to adult obesity, has been sadly neglected. Fewer
than a dozen controlled trials have been conducted with
adolescents. Most have examined lifestyle modification
99
programs that included dietary and exercise counseling,
behavioral modification strategies, and, in some studies,
parental participation. This approach is effective at producing moderate weight losses of 2–4 kg, with many adolescents remaining substantially obese (BMI C 35 kg/m2)
at the end of treatment (e.g. Robinson 1999; Johnson et al.
1997).
Within the past decade, investigators have tried a
number of strategies to maximize initial weight loss and
promote more successful long term maintenance (e.g.
Berkowitz et al. 2003, 2006, 2010; Oude Luttikhuis et al.
2009). These approaches have typically involved the
combination of behavioral treatment (BT) and either
pharmacotherapy or the use of meal-replacement products
designed to reduce portion sizes and control total caloric
intake. For example, Berkowitz et al. (2003) randomized
82 adolescents to BT with either placebo or sibutramine, a
medication designed to promote feelings of satiety. As is
often done in behavioral based treatment for weight loss,
adolescents in both conditions were instructed to consume
a self-selected diet of approximately 1300 kcal/d and were
encouraged to engage in C120 min per week of aerobic
exercise. At months 3 and 6, adolescents treated by BT?
sibutramine lost more than twice as much weight as those
treated by BT ? placebo (7.8 kg vs. 3.2 kg; p \ .001). The
BT? sibutramine group had an 8.5 ± 6.8% reduction in
initial BMI compared to a 4.0 ± 5.4% loss in the BT?
placebo group (p \ .001), suggesting that the combination
of BT and pharmacotherapy can be used to promote greater
weight loss.
Although these results were encouraging, the Food and
Drug Administration removed sibutramine from the United
States market in 2010 because of concerns about an association with heart disease. At present there is only one
medication, orlistat, approved for long-term usage in the
United States. However, as it is rarely covered by insurance, its usage by pediatricians to treat adolescents is quite
infrequent.
Furthermore, there are a number of additional limitations to both behavioral and pharmacologically based
treatments. First, while modest weight losses of 5–8% of
initial body weight may improve the health and psychosocial status of those with moderate obesity, they may have
little effect on the health and well being of the extremely
obese. Second, the majority of obese adults treated with
behavioral and pharmacologic treatments typically regain
weight over time. Little is known about successful, long
term weight maintenance in obese adolescents.
For these and other reasons, investigators have turned
their attention to bariatric surgery as a treatment for adolescents with extreme obesity who may have tried (and
failed) these more conservative treatments or for whom the
severity of their obesity is so great that the more modest
123
100
weight losses of these treatments are likely to have little
impact on their physical health and psychosocial status.
While this may sound preposterous to some, there is
compelling evidence to suggest that obese children and
adolescents are likely to become obese adults and, as a
result, be at risk for premature death (Whitaker et al. 1997).
This observation, coupled with the medical and psychosocial toll that obesity can take on an obese adolescent (as
noted above), provides further support for the need for
more aggressive interventions.
Surgical Treatment of Obesity
Bariatric surgery is the most effective weight control
option for obesity. Bariatric surgery is currently recommended for individuals 18 years and older with a
BMI C 40 kg/m2 (or a BMI [ 35 kg/m2 in the presence of
significant co-morbidities) (Consensus Development Conference Panel 1991). The most reliable statistics published
to date suggest that 103,000 individuals underwent bariatric surgery in the United States in 2003 (Santry et al.
2005); more recent estimates suggest that over 200,000
procedures are performed annually. Approximately 3,000
bariatric surgical procedures were performed on adolescents between 1996–2003, with a 3-fold increase between
2000 and 2003 (Tsai et al. 2007). These numbers are predicted to increase in the future. However, relatively little is
known about the safety and efficacy of bariatric surgery in
adolescents.
The patient selection criteria for adults interested in
bariatric surgery are well established. An American
Academy of Pediatrics expert panel developed guidelines
for considering bariatric surgery in adolescents (Inge et al.
2004b). In brief, the panel recommended surgery for
adolescents with BMI C 50 kg/m2 or BMI C 40 kg/m2 in
the presence of serious, obesity-related comorbidities. The
adolescent must have attained or nearly attained physical
maturity and have a history of organized attempts at
weight management without success. Finally, the adolescent must demonstrate reasonable decision making abilities, be willing to commit to the comprehensive medical
and psychological assessment process prior to surgery,
and understand and be willing to adhere to the postoperative nutritional guidelines. Readiness and motivation to
make long-term dietary and lifestyle changes are major
factors when determining if a candidate is appropriate for
bariatric surgery. If the patient is struggling to commit to
dietary changes required of surgery, it is often recommended that they enter a pre-surgical medical weightmanagement program or seek individual treatment from a
Registered Dietitian to help them better prepare for
surgery.
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The most common surgical procedures include laparoscopic adjustable gastric banding (LAGB) and the Rouxen-Y gastric bypass (RYGB). In both procedures, food
intake is limited by the creation of a gastric pouch
(approximately 30 ml in size) at the base of the esophagus.
RYGB operations have a restrictive component, but also
are thought to induce weight loss through selective malabsorption and favorable effects on gut peptides. The
stomach and part of the intestine are bypassed by attaching
the small pouch to a limb of the intestine, thus, limiting the
absorptive surface. Both types of operations are routinely
performed laparoscopically.
As has been reviewed in detail elsewhere, adolescent
obesity is associated with a number of untoward psychosocial characteristics, including increased symptoms of
depression and impaired self-esteem, body image, and
quality of life (e.g., Cooperberg and Faith 2004). Not
surprisingly, these issues may be even more profound in
adolescents with extreme obesity (e.g., Benoit Ratcliff
et al. 2011). For example, Kim et al. (2008) found that 22
of 25 (88%) adolescents received a psychiatric diagnosis
based on their psychological evaluation prior to bariatric
surgery (which is required by the vast majority of bariatric
programs and third party payers throughout the country).
Depression was the most common condition, diagnosed in
17 patients (65%). Four patients had anxiety disorders, one
of whom had concurrent depression. One patient had a
diagnosis of schizophrenia. Significant psychological
issues, such as uncontrolled depression, substance abuse,
thought disorders or significant family discord, typically
are considered contraindications to bariatric surgery.
Postoperative Outcomes
Two years postoperatively, adults typically lose 50–60% of
excess body weight with RYGB procedures and 40–50%
with the LAGB (Buchwald et al. 2004). There are a number
of small reports of comparable outcomes in adolescents
(e.g., Inge et al. 2004a; Sugerman et al. 2003). Weight loss
following bariatric surgery is associated with significant
improvements in obesity-related co-morbidities in adults
and adolescents. These impressive outcomes must be balanced by the incidence of complications. Early postoperative complications occur in 5–10% of patients, while late
complications have been reported in at least 25% of
patients (Buchwald et al. 2004). Approximately 25% of
patients fail to reach the typical postoperative weight loss
or begin to regain large amounts of weight within the first
few postoperative years (Sjostrom et al. 2004). Among
adolescents, 5 of 33 patients regained some or all of their
weight within the first decade after surgery (Sugerman
et al. 2003). These suboptimal results typically are
J Youth Adolescence (2012) 41:98–104
attributed to poor adherence to the postoperative diet or a
return of maladaptive eating behaviors (Sarwer et al. 2005).
Patients must adhere to a rigorous diet following bariatric surgery. In 2008, the American Society of Metabolic
and Bariatric Surgery (ASMBS) published the Allied
Health Nutritional guidelines for the Surgical Weight Loss
Patient (ASMBS 2008). After surgery, patients typically
begin with a liquid diet and progress to pureed and soft
foods during the first several weeks. At approximately
2 months postoperatively, patients typically return to a diet
of regular foods. Common dietary recommendations also
include using meal replacement products to control portion
sizes, reducing fat and sugar intake, reducing alcohol
consumption, increasing consumption of fruits and vegetables, consuming meals consistently throughout the day,
and preparing meals at home instead of eating out. A
commitment to life-long dietary changes is required
of patients undergoing any of the bariatric surgical
procedures.
Despite the guidelines, a number of studies have suggested that adherence to the postoperative diet is poor.
Caloric intake often increases significantly during the
postoperative period (Sarwer et al. 2008). These increases
in caloric intake likely contribute to weight regain, which
typically begins during the second postoperative year
(Sjostrom et al. 2004). While total caloric intake typically
increases during the postoperative period, a small subset of
bariatric surgery patients suffers from malnutrition. Most
cases of malnutrition among bariatric surgery patients
appear to be responsive to improved dietary adherence or
vitamin supplementation (Xanthakos and Inge 2006).
Nevertheless, these problems may be of greater relevance
for adolescent patients because of their developmental
status at the time of surgery, as well as their longer life
span.
Disordered Eating after Bariatric Surgery
Disordered eating, particularly binge eating, is thought to
be relatively common among candidates for bariatric surgery. Binge eating disorder (BED) is characterized by the
consumption of an objectively large amount of food in a
brief period of time (i.e., 2 h) with the patient’s report of
subjective loss of control during the overeating episode
(Spitzer et al. 1992). Patients with BED do not engage in a
compensatory behavior, such as vomiting, laxative abuse,
or excessive exercise, following the binge episode, which
distinguishes BED from bulimia nervosa. Although initial
reports suggested that up to 50% of adult bariatric surgery
patients may suffer from the disorder, more recent studies
suggest that approximately 5–15% of patients have the
condition (e.g., Allison et al. 2006).
101
Estimates suggest that less than 3% of obese adolescents
meet criteria BED (Johnson et al. 2002). The prevalence of
sub-threshold binge eating among overweight adolescents
who present for weight loss treatment, however, is considerably larger (20–30%) (e.g. Decaluwe et al. 2003;
Glasofer et al. 2007; Isnard et al. 2003). A few studies have
looked at binge eating behavior in adolescents who presented for bariatric surgery. Zeller et al. (2006) found that
13% of candidates for bariatric surgery reported symptomatology consistent with a diagnosis of BED, a rate
comparable with a comparison group of extremely obese
teenagers not interested in surgery (15%).
Studies have found that, after bariatric surgery, a significant minority of patients reported feelings of loss of
control consistent with BED. In other studies, it appears
that binge eating is related to smaller weight losses, or
weight regain within the first two postoperative years (e.g.,
Kalarchian et al. 2002) even though bariatric surgery
makes it impossible for them to eat excessively large
amounts of food. This may be caused by stretching of the
gastric pouch, allowing for increased food intake over time.
A recent study, however, suggested no differences in
weight loss at 1 year after surgery in persons with and
without BED (Wadden et al. 2011).
Psychosocial Outcomes after Bariatric Surgery
As reviewed in detail elsewhere, numerous studies have
found that the majority of adult bariatric patients experience psychological improvements postoperatively (e.g.,
Sarwer et al. 2005). Most psychosocial characteristics,
including self-esteem, depressive symptoms, health-related
quality of life, and body image improve dramatically in the
first year after surgery. These psychosocial benefits, however, may be limited to the first few postoperative years.
The impact of bariatric surgery on longer-term psychological functioning is largely unknown.
Despite the impressive psychological improvements
following surgery, there appears to be a small yet significant minority of patients who experience behavioral
or psychological complications following bariatric surgery. These complications include depression and suicide,
disordered eating, body image dissatisfaction, sexual
dysfunction and/or marital discord, and substance abuse
(Sarwer and Fabricatore 2010). There is a similar, if not
greater, concern for these and other psychological complications in teenagers who undergo bariatric surgery.
This population has a high prevalence of psychological
dysfunction and disordered eating practices. Detection
and treatment of these psychological and behavioral
problems may be of particular importance during
adolescence.
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102
Conclusions and Future Directions
Our country’s obesity problem has gone essentially
unchecked for the past several decades. A majority of
Americans are currently overweight or obese. Many of
those individuals are suffering from significant weightrelated health problems which may threaten their life
expectancy. Furthermore, the health care costs associated
with treating these conditions, on both the individual and
societal level, are staggering and represent a significant
threat to our country’s economic well being over the next
several decades.
Although there is much greater awareness of these
issues than before, researchers, clinicians and policy
makers have made little progress to date. The past decade
has witnessed an increased emphasis on prevention, particularly among American youth. Unfortunately, studies of
the effectiveness of prevention efforts have not been
encouraging (e.g., Foster et al. 2010). On the individual
level, behavioral and dietary treatments typically lead to
modest weight losses and corresponding improvements in
health. Unfortunately, these benefits are rarely maintained
beyond the period of active treatment, leaving many
patients back where there they started with regard to their
weight and health, and discouraged about their ability to
reduce and maintain their weight in the future.
This cycle is particularly concerning when we consider
the growth of childhood and adolescent obesity. It is very
disconcerting to consider the potential psychological toll
that obesity can have on a child growing up in a culture that
overemphasizes and equates thinness with physical beauty.
Add to the mix frustration of repeated weight loss and
regain, as well as the societal and economic burden of
obesity noted above, and it is hard not to be discouraged
when thinking about childhood obesity.
For these as well as other reasons, bariatric surgery has
become an increasingly popular treatment option for adults
with extreme obesity. The postoperative weight losses are
sizable and typically lead to significant improvements in
obesity-related comorbidities and psychosocial status.
However, a significant minority of patients appears to
struggle with these issues, and, as a result, experience
suboptimal weight losses or premature and significant
weight regain. Thus, there is growing consensus that
improvements in dietary intake and eating behaviors are
critical to long term success following bariatric surgery.
There has been little study of these issues in adolescents
who undergo bariatric surgery. Dietary intake and eating
behaviors may be of even greater importance for adolescents who undergo surgery because of their maturational
status and longer life expectancy. Over the past several
years, the National Institutes of Health has been funding
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J Youth Adolescence (2012) 41:98–104
the Teen-Longitudinal Assessment of Bariatric Surgery
(Teen-LABS) consortium. The primary objective of the
consortium is to investigate the safety and efficacy of
bariatric surgery in adolescents (Inge et al. 2004c). Adolescents (19 years old or younger) are being recruited from
five sites: Cincinnati Children’s Hospital Medical Center,
Texas Children’s Hospital, Children’s Hospital of Alabama, Nationwide Children’s Hospital, and University of
Pittsburgh Medical Center.
The Teen-LABS consortium also is supporting a number
of ancillary studies specifically focused on psychological
and behavioral issues. One such study is investigating
changes in a variety of psychosocial domains, including
depressive symptoms, quality of life, body image, and
other issues related to socialization, including participation
in high-risk health behaviors that may put these adolescents
at increased risk for some of the poor psychosocial outcomes detailed above. Another study is looking at changes
in eating behavior and dietary intake after surgery to see if
adolescents are able to successfully adhere to the rigorous
postoperative diet as they transition into early adulthood.
These as well as the other studies in the consortium will
provide both medical and mental health professionals with
vitally important information about the efficacy of bariatric
surgery for adolescents.
In summary, obesity represents one of the Western
world’s most significant health problems. Rates of obesity
among both adults and adolescents have risen dramatically
over the past several decades. The most popular weight loss
treatments—lifestyle modification and pharmacotherapy—
typically produce modest weight losses which may
improve some weight-related health problems. Unfortunately, most individuals who use these treatments regain
their weight within a few years and, as a result, return to
being obese. This cycle of weight loss and regain is particularly concerning for adolescents, who may end up living with obesity, and its associated medical and mental
health consequences, for decades. This scenario, whether
considered from the individual or societal level, is sobering. At the present time, bariatric surgery holds the greatest
promise in promoting larger and sustained weight losses
which are associated with significant improvements in
weight-related comorbidities. Unfortunately, only one
percent of adults who are heavy enough for surgery currently receive it; the percentage is even smaller for adolescents. This intersection of circumstances—a growing
public health problem, a lack of effectiveness of the most
common treatments, and an under-utilization of the most
efficacious treatment—will challenge professionals from
countless disciplines to work together in novel and creative
ways to combat the daunting obesity problem facing youth
around the world.
J Youth Adolescence (2012) 41:98–104
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Author Biographies
David B. Sarwer is Associate Professor of Psychology in Psychiatry
and Surgery at the University of Pennsylvania School of Medicine as
well as Director of Clinical Services at the Center for Weight and
Eating Disorders. He received his doctorate in clinical psychology
from Loyola University Chicago. His major research interests include
the psychosocial and behavioral aspects of obesity.
Rebecca J. Dilks is a Research Coordinator at the Center for Weight
and Eating Disorders. A Registered Dietitian and a Licensed
Dietitian-Nutritionist, Ms. Dilks received a B.S. from Immaculata
University. Her major research interests focus on the nutritional
management of obesity.
NATIONAL ASSOCIATION OF SOCIAL WORKERS
NASW
Standards
for
t h e P r a c t i c e o f S o c i a l Wo r k w i t h
Adolescents
NASW
Standards
for
t h e P r a c t i c e o f S o c i a l Wo r k w i t h
Adolescents
National Association of Social Workers
Gary Bailey, MSW
NASW President (2003–2005)
NASW Partners in Program Planning
for Adolescent Health (PIPPAH)
Advisory Committee Standards
Task Force (2002–2003)
Marvin Hutchinson Jr., MSW, LISW
Frank Irigon, MSW
Elaine Johnson, MSW
Homer Rahn-Lopez, MSW
Rufus Sylvester Lynch, DSW, LSW
Dennis Poole, PhD
Kristine Siefert, PhD, MPH
Lann E. Thompson, EdD, LCSW, ACSW
Darrell P. Wheeler, PhD, MPH
NASW STAFF:
Elizabeth J. Clark, PhD, ACSW, MPH
NASW Executive Director
Toby Weismiller, ACSW
Director, Professional Development
& Advocacy
Tracy Whitaker, ACSW
Laurie Emmer, LICSW, LCSW-C
©2003 National Association of Social Workers
All rights reserved
Contents
5
Introduction
8
Standards
8
Standard 1. Knowledge of Adolescent Development
9
Standard 2. Assessment
10
Standard 3. Knowledge of Family Dynamics
11
Standard 4. Cultural Competence
12
Standard 5. Self-Empowerment of Adolescents
13
Standard 6. Understanding Adolescents’ Needs
15
Standard 7. Multidisciplinary Case Consultation
15
Standard 8. Confidentiality
16
Standard 9. Work Environment
17
Standard 10. Advocacy
18
Standard 11. Policies for Effective Practice
20
Resources
Adopted by the NASW Board of Directors
June 28, 2003
Introduction
Adolescence marks an important time in the
process of human development, the passage between
childhood and adulthood. It is a time of tremendous
opportunity and promise, when young people
begin to explore their burgeoning individuality
and independence and begin to think critically
about themselves and the world around them.
They begin to adjust and adapt to the profound
biological, psychological, and social changes and
challenges that are by-products of adolescence.
The manner in which adolescents navigate these
changes and challenges is largely a function of
interactions—both positive and negative—with
families, communities, and the larger social
environment. The health and well-being of our
young people (and the adults they will become)
are critically affected by their experiences during
this developmental milestone.
Healthy adolescent development depends on safe
and supportive environments that are free from
violence and from the risks of physical, mental,
and emotional harm environments that provide
opportunities for youths to build strong and
meaningful connections with their families, their
schools, and their communities. Adolescents
greatly benefit from engagement in activities in
which their value is demonstrated and affirmed
and their inherent talents, capabilities, and
strengths are enhanced. Social environments that
are inclusive and accepting of diversity encourage
all youths to feel good about and value themselves
and others around them. Equitable access to quality
education, health care, employment opportunities,
and social supports also are essential for ensuring
positive outcomes for youths.
5
Most young people are able to navigate these
adolescent years successfully with the support of
caring families and communities. Far too many
youths, however, experience significant challenges
during this time that impede their ability to
move successfully into adulthood. The healthy
development of adolescents is thwarted by the
invasion of drugs and violence into homes,
schools, and social environments. Impoverished
conditions may offer limited or no access to basic
needs and present barriers for youths and their
families. These barriers prevent access to adequate
health care and social services, education,
employment opportunities, housing, and nutrition.
Youths also may be exposed to violence, abuse,
bullying, harassment, and neglect in their homes,
schools, and communities.
Some youths may experience alienation,
disenfranchisement, and discrimination from the
families, communities, and social institutions
charged with supporting their development.
Youths with severe health and mental health
problems or disabilities, runaway and homeless
youths, youths in foster care or juvenile justice
systems, and gay, lesbian, bisexual, and transgender
adolescents often experience alienation. These
social conditions leave young people more
vulnerable to health-damaging behaviors such as
substance abuse, delinquent activities, unprotected
sexual activity, and mental health pathology.
Social workers understand that everyone—
individuals, communities, and society as a
whole—reaps the benefits from investments in
helping our young people achieve optimal physical
and mental health. Social workers provide essential
services in the environments, communities, and
social systems that affect the lives of youths. To
6
meet the needs of young people, it is important
for social workers to demonstrate a fundamental
knowledge and understanding of adolescent
development and the critical role of biopsychosocial
systems.
As the largest professional organization of social
workers, the National Association of Social
Workers (NASW) expects social work with
adolescents to be carried out by people who have
the necessary competence, knowledge, and values.
Thus, NASW establishes standards to define and
describe professional social work practice. These
Standards for the Practice of Social Work with
Adolescents are designed to guide social workers in
a variety of settings as they help young people
become competent and healthy adults. The
unique perspectives and breadth of social work
practice provide systemic linkages between the
social work profession and the social entities that
affect adolescent development. Adequately meeting
the needs of youths means engaging all systems—
individual, family, and the broader community—
in efforts to prevent problems and promote
health and well being.
7
NASW Standards for the
Practice of Social Work with Adolescents
Standard 1. Knowledge of Adolescent Development
Social workers shall demonstrate knowledge and
understanding of adolescent development.
Interpretation
Essential areas of knowledge and understanding
about positive adolescent development include
■
human growth and behavior, including
developmental stages, human needs, motivations,
feelings, behaviors, activities of children and
youths, and cultural differences
■
the role of adolescence in individuals’ social,
physical, emotional, and sexual growth,
including adolescents’ striving for and
ambivalence about independence, competence,
achievement, personal identity, and sexuality
■
the critical role of education in healthy
adolescent development and the barriers to a
successful educational experience
■
the necessity to recognize the needs of
adolescent development
■
the impact of substance abuse and violence on
adolescents’ development and on their families
■
the family, school, community, and cultural
process for allowing and helping adolescents
become independent
■
the importance of opportunities for adolescents
to establish positive relationships with open
expression of thoughts and feelings with family
members, peers, and role models such as
teachers, clergy, and sports team coaches
■
the significance of adolescents’ steps in
establishing an identity, which may include
a natural form of rebelliousness and rejection
of authority.
8
Standard 2. Assessment
Social workers shall demonstrate an ability to
assess adolescent services, including access to
social
institutions
and
community-based
resources that provide services for adolescents
and their families, and shall advocate for the
development of needed resources.
Interpretation
Social workers shall possess the following
fundamental knowledge and skills to work
effectively with adolescents and their families:
■
the history and development of social work
and its person-in-environment perspective
■
the theory, principles, and methods of social
work, including casework, group work,
community organization, administration,
supervision, planning, and research
■
the influence of cultural beliefs, background,
lifestyles, and ethnicity
■
the interrelationships among the individual
and the family, the group, the neighborhood,
the community, and social systems
■
the purpose, structure, legal mandates, and
services provided by public and voluntary
social welfare, child welfare, and youth
services agencies; schools; and health, mental
health, juvenile justice, and law enforcement
organizations
■
an ability to coordinate with other professionals
and community organizations and advocate
for their involvement on behalf of youths
■
the political and economic factors affecting
adolescents, their families, and their communities
■
multidisciplinary and team approaches for
working with children and youths, and the
contributions from biomedical, psychological,
social sciences, legal, educational, law
enforcement, and other disciplines
9
■
opportunities available to adolescents for
training to increase job-related skills
■
an understanding of the importance of
working with adolescents in the environments
in which they feel comfortable, including
nontraditional environments
■
familiarity with groups who provide peer
education and improve youths’ decision making
and leadership skills
■
understanding of and ability to develop a case
plan jointly with youths and their families
■
an understanding of how to develop
programs that provide comprehensive services
to adolescents to prevent fragmentation
■
an understanding of how to develop programs
that will increase the likelihood that youths
will use available services for the range of
issues that affect adolescents (for example,
reproductive health, HIV/AIDS and other
STIs, violence, and abuse).
Standard 3. Knowledge of Family Dynamics
Social workers shall demonstrate knowledge and
understanding of family dynamics and systems
theory.
Interpretation
NASW defines families as two or more people
who consider themselves “family” and who assume
obligations, functions, and responsibilities
generally essential to healthy family life.
Essential areas of knowledge about family
dynamics include
■
family dynamics in traditional and nontraditional
families, including two-parent, single-parent,
and foster and adoptive families and unrelated
individuals living together as a family, and
acceptance and understanding of such family
constellations
10
■
the impact of adolescents’ parents’ growth
experiences, attitudes, and behaviors and
culturally relevant ways for parents to ask for help
■
an understanding of how to bring about
changes in family functioning
■
the concept of family culture, including the
role of the family in meeting the changing
physical, mental, spiritual, and emotional
needs of adolescents
■
cultural attitudes toward the responsibilities
of each family member
■
the impact of impairment and disability,
including mental and emotional disabilities,
chemical dependency, and abusive conditions on
positive adolescent development and family
dynamics
■
an understanding of changing parental roles
and the diversity among those roles
■
the impact of economic, social, and cultural
conditions on parental ability to meet family
responsibilities.
Standard 4. Cultural Competence
Social workers shall demonstrate culturally
competent service delivery.
Interpretation
The increasingly diverse population in the
United States requires that social workers raise
their awareness and appreciation of cultural
differences. They must develop competencies
that include heightened self-awareness, knowledge,
and practice skills consistent with the NASW
Standards for Cultural Competence in Social Work
Practice (NASW, 2001).
Culturally competent social workers should be
knowledgeable about the deleterious effects
of racism, sexism, ageism, heterosexism or
11
homophobia, anti-Semitism, ethnocentrism,
classism, and disability-based discrimination on
adolescents’ lives and about the need to advocate
for and with adolescents.
Social workers must recognize racial, ethnic,
gender, and cultural differences that may be
interpreted as barriers and develop strategies and
skills to ameliorate such barriers.
Standard 5. Self-Empowerment of Adolescents
Social workers shall help adolescents achieve selfempowerment.
Interpretation
Social workers should demonstrate the necessary
knowledge and skills to ensure the participation
of adolescents in decisions about the programs
and services designed to meet their needs. This
includes
■
encouraging youths and their families to be
active participants in their case planning and
service delivery
■
developing adolescent leaders to provide peer
support to other adolescents and supporting
their efforts
■
advocating for youth positions and roles of
influence on agency boards or committees
and providing training for youths to develop
the skills needed to improve existing services
and develop necessary services
■
working with youths and their families to help
them assume responsibility for following
through on a plan of action and for securing
and using planned services
■
providing or brokering the training and
support to help youths develop independent
living skills.
12
Standard 6. Understanding Adolescents’ Needs
Social workers shall advocate for an understanding
of the needs of adolescents and for resources and
cooperation among professionals and agencies to
meet those needs.
Interpretation
Social workers who work with adolescents should
respect and work to strengthen the many protective
factors that are sometimes overlooked or
ignored. Appropriate and effective work with
adolescents requires an understanding of the
developmental skills and tasks characteristic of
the age, an awareness of the psychosocial and
emotional phases of adolescence, and clinical
knowledge of inappropriate behavior and symptoms
of mental illness or stress. Social workers should
be aware that adolescents’ behaviors and attitudes
may provoke ambivalent or negative feelings in
those who work with this age group.
Social workers need to be aware of adolescents’
multidimensional lives, regardless of service
focus. This includes the family, siblings, extended
family, individuals with whom the adolescent may
reside, peer group, friends of the opposite sex,
religious affiliation, physical and mental health,
cultural and economic facts, refugee status,
discrimination experiences, and exposure to
violence in the community or family or from war
experiences. In advocating for adolescents, social
workers must work to ensure that
■
continuing education is available for
providers, professionals, and families of
adolescents to develop skills and a knowledge
base, to acknowledge and enhance adolescent
protective and resilient factors, and to
strengthen empowerment capacities and
decision-making skills
13
■
community services are responsive to the
mental health, physical, medical, educational,
vocational and occupational training, housing,
and other needs of adolescents as articulated
by adolescents and their families
■
agencies provide opportunities for staff to
recognize and take appropriate actions to
resolve their own biases, fears, or antipathy
about behaviors exhibited by adolescent clients
■
policies and programs adjust, change, or
accommodate to meet the needs of adolescents
in different settings and with different
disabilities or mental or physical limitations
■
opportunities are provided for adolescents to
discuss, learn about, and appreciate the
uniqueness of different cultures, personalities,
and interactions
■
knowledge is increased about medical and
substance abuse issues, methods of fostering
healthy attitudes, interventions, and behavior
toward drug use among targeted youths
■
improved school connections are encouraged
to improve academic performance, school
attendance and behavior, and attitudes toward
learning and achievement
■
opportunities for strong relationships with
adults and peers for positive and supportive
interaction are available
■
information about model programs for
prevention and treatment is available
■
information is disseminated on the effects of
alcohol, substance abuse, domestic and dating
violence, and HIV/AIDS to families and
communities
■
information, news, and updates about pressures
on adolescents from different cultures, income
levels, and ethnic groups are routinely provided
■
opportunities to identify and address risk-taking
behavior are available in community forums
14
and parent groups, as well as with educators,
juvenile justice staff, and law enforcement officials
■
opportunities for collaboration among
community, religious, and athletic groups are
supported
■
opportunities exist to recognize adolescent
achievements.
Standard 7. Multidisciplinary Case Consultation
Social workers shall participate in multidisciplinary
case consultation across agencies that provide
services to adolescents.
Interpretation
To develop the most appropriate case plan with
adolescents and their families, social workers
must consult with other individuals, professionals,
and organizations who work with adolescents
without violating confidentiality.
Such consultation should include
■
joint assessment of youths’ presenting
problems, family strengths, and risk factors
■
joint assessment of the need for available
services and interventions
■
individual evaluations of adolescents’
progress and joint consultation following
the evaluations
■
joint appraisal of youths’ successes and
failures when the cases are closed and
assessment of alternatives that were available
for the case plan
■
involving adolescents and their families in
care planning
Standard 8. Confidentiality
Social workers shall maintain adequate safeguards
for privacy and confidentiality in their relationships
with youths.
15
Interpretation
Respect for the client as a person and for his or
her right to privacy underlies the social worker–
client relationship. Except for federal, state, or
local legal and other overriding requirements, the
social worker will share information only with the
informed and signed consent of the youth, the
family, or both. Although assurance of confidentiality
enhances the relationship and the willingness of
the youth to develop and adhere to a case plan,
the youth should be advised that there are
circumstances in which confidentiality cannot be
maintained. These situations may include
■
suspicion of child abuse or neglect, which
requires that appropriate authorities be notified
■
suspicion of danger to the youth or to others.
In all such situations, the social worker
shall advise the youth of the exceptions to
confidentiality and privilege, shall be prepared
to share with the youth the information that
is being reported, and shall appropriately
address the feelings evoked.
Standard 9. Work Environment
Social workers shall assume an active role in
contributing to the improvement and quality of the
work environment, agency policies and practices
with clients, and their own professional development.
Interpretation
Social workers are responsible, in part, for their
own empowerment as staff of the organizations
in which they work. As integral members of an
agency, social workers who work with adolescents
are to conform to the mission and expectations
established by that agency. Social workers should
■
initiate action to ensure that agency policies and
practices establish reasonable expectations that
allow them to perform their jobs most effectively
16
■
work for constructive change so that the work…

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