• Unintentional and intentional injury are often linked to alcohol and drug use, smoking, unsafe sexual practices, poor diet and physical inactivity. (3, 9)

• According to 1997 Census data, more than half of deaths among adults over the age of 40 are caused by cardiovascular disease and cancer, which are associated with significant behavioral risk factors, such as tobacco use, poor nutrition and low physical activity.

• Most of the above behaviors emerge during childhood and adolescence. (14, 3, 9) Furthermore, individuals engaging in one type of behavior also often engage in other of these behaviors. (5,6)

• Seventy-three percent of deaths among those ages 10 to 24 are due to three leading causes, all of which are related to behavior. Forty percent of those deaths are due to unintentional injury (particularly from motor vehicle accidents), 20 percent are due to homicides and the remaining 13 percent are due to suicide. (2) Alcohol and illegal substances are often play a part in these deaths. (4, 13)

• About 800,000-900,000 pregnancies and 3.75 million cases of sexually transmitted diseases occur annually among adolescents. (10,11) The prevalence of behaviors associated with pregnancy and STDs is significant in that 48 percent of high school students reported engaging in sexual intercourse at least once, with 43 percent of those who were sexually active not having used a condom during their last sexual intercourse.(15)

• A substantial body of research has helped establish that beneficial health behaviors can lead to a lifetime of good health and that these choices are encouraged by programs that incorporate social and emotional competence enhancements. (17)

Interview #1:

Applying Social and Emotional Competence

Roger P. Weissberg, Ph.D., is a professor of psychology and education at the University of Illinois at Chicago. He directs an NIMH-funded Prevention Research Training Program in Urban Children’s Mental Health and AIDS Prevention and is currently chair of the Psychology Department’s Division of Community and Prevention Research. Dr. Weissberg also is executive director of the Collaborative to Advance Social and Emotional Learning (CASEL), an international organization committed to supporting the development and dissemination of effective school-based programs that enhance the positive social, emotional, academic, moral and healthy development of young people.

Q-What are the goals of programs integrating social and emotional competence?

A- Effective school-based programs that teach social and emotional competence, also called social and emotional learning, have two main goals. (20) First, they provide systematic classroom instruction that enhances children’s capacities to recognize and manage their emotions, appreciate the perspectives of others, establish socially beneficial goals and solve problems as well as use a variety of interpersonal skills to effectively and ethically handle developmentally relevant tasks. Second, these programs establish environments that support, reinforce and extend this instruction so that children generalize what they learn in the classroom to daily life outside the classroom. SEC programs have been shown to improve health-protective behaviors, academic success and positive social relationships, and have also prevented negative outcomes such as drug use, aggression and high-risk sexual behavior.

Q-What are the skills that such programs help children develop?

A-Some of the key social and emotional competencies include emotional awareness, impulse control, stress management, adaptive goal setting, problem solving, responsible decision making and communication. For example, my colleagues and I designed a 45-session social competence promotion program for young adolescents that taught SEC skills using a traffic signal. (18) With the red light, teachers taught students to stop, calm down and think before you act. This involved teaching impulse control, stress management skills and getting ready to handle problem situations. The yellow light covered four steps: Say the problem and how you feel, set a positive goal, think of lots of solutions and think ahead to the consequences. These steps enhance children’s abilities to analyze situations, identify feelings in themselves and others, set their goals, generate alternative solutions and anticipate the personal and social consequences of actions -- both short and long-term. The green light ("Go ahead and try the best plan") involves learning how to implement a solution; communication skills such as timing and tone of voice and overcoming obstacles and being persistent.

Q-How do kids apply these skills to help them make better health behavior decisions?

A-Children do not automatically apply problem-solving and decision-making skills to their health behavior. Many SEC programs teach children a general problem-solving framework and then provide opportunities so that children can apply these skills to cope more effectively with developmentally appropriate social and health situations. In other words, if you want to prevent drug use, violence or high-risk sexual behavior, it helps to teach children a combination of general and specific skills so that they can handle these risks adaptively. For example, in teaching kids drug-use refusal skills, it’s important to connect real-life situations in which they’ve confronted these sort of decisions. It’s also important to connect these skills to their prior knowledge and experience -- then we can teach them to apply the skills in the context of what they might have been exposed to in the past, what they may be thinking about in the present or what they might be exposed to in the future. Additionally, SEC programs teach parents and teachers to communicate effectively with children to encourage the effective application of social and emotional competencies to real-life decisions about health.

Q-There are many other factors that can influence kids – school environment, stress, peer pressure, family situation. How much can SEC help prepare young people to make good decisions in the face of these other influences?

A-SEC can enable people to anticipate these situations and cope with them more effectively. Instead of being overwhelmed by a situation, if you can step back and understand the situation and how it makes you feel and behave, then you can say to yourself, "I tried this solution and it led to this outcome and I know that didn’t work, so next time I can try another strategy and maybe that will be more effective." Kids may experience all kinds of stressful situations – for example, going to a party where there is alcohol or having someone "dis" you in front of friends. In the heat of the moment, you don’t always handle these interactions in the best possible way. SEC programs provide a chance to reflect upon or anticipate situations that are likely to arise and to think of ways to cope more successfully in a variety of future situations. That doesn’t mean you’ll be totally prepared, but it does mean in the grander scheme of things, you’ll be able to handle things more effectively and have a more realistic and positive outlook on what you can achieve.

Q-How convincing is the evidence that SEC affects health behaviors in children and adolescents and helps them make better health decisions?

A- A growing body of research has documented that drug prevention, sex education, violence prevention and health education programs improve health decision making and behavior when they include well-designed training in social-emotional competence as a core part of the intervention. Programs that enhance children’s competence through the coordinated efforts of parents, teachers, peers and the community are most likely to be beneficial.

Q-Are SEC skills generally taught in school or can they be taught by parents?

A-SEC skills can be taught by both teachers and parents. Members of CASEL believe it is best to establish school, family and community partnerships to teach kids these skills, create opportunities for them to use these skills, and to reward kids when they apply the skills effectively. The best programs are often taught in school by teachers, who have continuing contact with kids and who collaborate with families. It’s important that teachers and parents are giving kids coordinated and mutually supportive messages.

Interview #2:

The Evidence: SEC’s Impact on Health

Jan Wallander, Ph.D., is professor of psychology and nursing and senior scientist at the University of Alabama at Birmingham’s Civitan International Research Center. He recently conducted a review of the literature on the impact of social and emotional competence on health behaviors for the Collaborative to Advance Social and Emotional Learning and for the Center for the Advancement of Health.

Q-How effective is social and emotional competence in helping children and adolescents avoid alcohol, drugs, tobacco and unintended pregnancy?

A- It’s quite clear from the literature that the programs that include components to promote SEC tend do noticeably better than programs that just provide health education or information. The addition of SEC enhancement definitely appears to have the desired impact of augmenting prevention programs. However, we can’t definitively point to SEC as the critical component because we haven’t studied SEC as a stand-alone intervention; it’s always in combination with health information and education programs. But the conclusion is that programs that emphasize social process over and beyond just education, and programs that emphasize the development of social and emotional competence, show a considerably stronger effect than those that just provide information.

Q-Does the current literature shed light on how SEC mediates this additive benefit?

A-Findings from a meta-analysis suggest that the positive effects of programs focusing on SEC enhancement are largely attributable to an increase in attitudes that are inconsistent with substance use.(19) Attitudes were generally not changed in the programs without an SEC enhancement focus. For example, we commonly observe that positive self-attitudes emerge in children receiving SEC training, along with the attitude that what they do makes a difference in the way that things turn out for them.

Q-Can you give an example of successful SEC-enhancement programs?

A-First, alcohol and drug prevention programs that enhance SEC have shown considerable differences in effect from the programs that simply convey instructional information. Across SEC programs you have an average success rate of 9.5 percent. That sounds small, but in public health efforts that is a very large number. For example, the success rate reported for the effects of aspirin in preventing heart attacks that resulted in public health recommendations was only 3.5 percent

A prime example of a successful SEC program is a randomized controlled trial conducted in the 1980s involving about 6,000 7^th grade students. That program was designed to reduce alcohol and tobacco use. The study found that those in the group that received SEC enhancement had significant differences in use of alcohol, marijuana and tobacco compared with those who received only health education. The effect on substance use was seen as long as six years later. (1)

The prevention program, which provided information and also taught personal and social skills, consisted of 15 class periods in 7^th grade and 10 booster sessions in 8^th and 9^th grade. Not only did researchers see a significant difference six years later in effects on alcohol use, marijuana use and tobacco use, but those who had the SEC enhancement also had better effects in terms of heroin, PCP use and inhalants, even though such substances weren’t targeted directly in the program. It showed that kids who acquire these skills tend to generalize them across substances. Kids learned to avoid alcohol or tobacco and applied these skills more generally against other harmful substances.

Q-What about pregnancy and sexually transmitted disease?

A-There are many examples of programs with components of SEC enhancement that show reduction in pregnancy rates compared to schools where such programs aren’t available. Although methodologies used in these studies do not allow us to attribute the positive effects specifically to SEC enhancement, the situation is somewhat different for the AIDS prevention studies. In terms of preventing AIDS or reducing the AIDS risk, a review of 40 such studies (7) found that the majority of programs had positive effects when they included decision-making, communication and social skills, which are important SEC components. Among these programs, 89 percent reported improved AIDS knowledge. Sixty-five percent found a significant effect on attitudes toward AIDS protective behavior, such as intention to use condoms. Eighty-two percent found a significant effect on actually using condoms, and 70 percent had an impact on the number of sexual partners.

Q-Are there connections between SEC and diseases such as cardiovascular disease, cancer and conditions affecting the immune system?

A-This is a very exciting area of research. I have been quite struck with the variety of scientific evidence that establishes a link between behavioral factors in adults and health status. For example, research has shown that higher social status and social support are associated with less likelihood of developing a cold. There are many findings like that showing measurable effects of social and emotional factors on health outcomes. They add up to a very compelling story: the way we feel and think and relate to others definitely has an impact on our biology, our health and our disease experience. Has that been proven? There isn’t just one study that we can point to; it’s a matter of looking at the collection of evidence. It is quite compelling, particularly as it relates to cardiovascular disease and immune functioning.

For example, how we react to stress psychologically is a component of SEC. Psychological reactivity is linked to biological reactivity. There is emerging evidence that stress-induced cardiovascular reactivity is positively associated with left ventricular mass, which in turn is associated with other heart disease factors, such as ventricular remodeling. This is just one example; there are several other pathways by which SEC can be linked to cardiovascular disease processes.

Another area garnering a lot of attention is the relationship between various behaviors and neuroimmunological processes. While most of this work has concerned adults, research is beginning to show that these associations also exist in children. It has been shown across several studies that the way environmental stress, such as entry into school or having family difficulties, is experienced, which is one aspect of SEC, is linked to measured immune regulation in children and the incidence of respiratory illness.

Although more research is needed, I find the accumulation of these kinds of findings already very persuasive. You have to begin to wonder why social and emotional considerations aren’t readily accepted as a part of health care. Numerous factors clearly play a role in health, but we have a lot of reason to believe that socially and emotionally competent individuals are on the average healthier, and SEC can be enhanced through high-quality interventions.

CASE STUDY: Project Northland Improves Teen Alcohol, Smoking Rates

Alcohol is the drug of choice for America’s teens. It is also the drug that causes the most harm to adolescents. Alcohol-related traffic crashes are a major cause of death and disability among teens and other leading causes of death among youth -- homicide, suicide and drowning -- are tied to acute alcohol intoxication as well (16). Moreover, teens who drink are more likely to become sexually active earlier, are more likely to have school-related work and conduct problems and are more likely to develop alcohol dependence, than those who wait (16).

Project Northland, a community-based alcohol use prevention effort, was established to battle this public health problem in northeastern Minnesota by trying to delay the age when youth start drinking and to reduce alcohol use among youth. Since it was initially funded by the National Institute on Alcoholism and Alcohol Abuse more than a decade ago, Project Northland, the nation’s largest alcohol use prevention trial, has become a model for programs both in the United States and abroad.

Project Northland’s multilevel, community-based approach incorporated key aspects of social and emotional learning. The intervention component of the research effort consisted of three years of social-behavioral health curricula in 6^th, 7^th and 8^th grade, extracurricular peer leadership, parental involvement and education and community-based activities. It was designed to offer comprehensive training in social competency, particularly related to alcohol use, according to Cheryl Perry, Ph.D., professor in the University of Minnesota’s School of Public Health and Project Northland’s principal investigator.

Involving 24 school districts and 28 adjoining communities in northeastern Minnesota, Project Northland encouraged 6^th graders and their parents to talk about alcohol-related issues by encouraging fun and educational activities at school and at home. The 7^th-grade curriculum was focused on peer-led classroom sessions that combined experimental activities with teaching students social skills in an attempt to delay the onset of drinking. The 8^th graders were engaged in an interactive program designed to reiterate messages and behaviors learned in the previous two years. They also learned how to communicate with the community at large about alcohol prevention.

Here’s what Project Northland accomplished (12):

-At the end of 8^th grade, monthly drinking among students in the intervention group was 20 percent lower than those who did not have the SEC-related program and weekly drinking was 30 percent lower.

-Use of both alcohol and cigarettes at the end of 8^th grade was 27 percent lower for students in the intervention group versus students in the control group.

-Students in the intervention group who indicated at the beginning of 6^th grade that they never drank were not only significantly less likely to drink during the duration of the program, but were also 37 percent less likely to smoke cigarettes and 50 percent less likely to smoke marijuana than students in the control group at the end of 8^th grade.

The program "had a kind of ripple effect, even though we weren’t dealing with tobacco and marijuana," Perry said. Project Northland was effective in changing peer influence and expectations regarding youth drinking and parental involvement in talking about the consequence of drinking and reasons not to drink.

Perry said parents of the 6^th graders getting the intervention didn’t think discussing alcohol was appropriate at the beginning of the school year but realized through the year that it, indeed, is the proper time to begin this conversation with youngsters.

"The kids are being exposed to things and changing much more rapidly than parents think," Perry said. "It’s as much about giving parents skills…as it is giving kids skills."

What Parents Can Do to Facilitate Social and Emotional Learning

Although social and emotional learning efforts to build SEC are often school based, parents’ involvement is an essential ingredient for children to effectively learn healthy behaviors.

Research shows that programs that effectively impart social and emotional competence involve multiyear school and home-school partnership planning efforts, says Jonathan Cohen, Ph.D., president and co-founder of the New York City-based Center for Social and Emotional Education. It’s important for parents’ actions to be consistent with what their children are taught in programs incorporating social and emotional learning. For example, if children are learning about conflict solution in creative, nonviolent ways and then hear a parent yelling at a teacher, they will be confused. Consistency between parents' actions and what children are learning in such programs sends a powerful and reinforcing message to children, Cohen says.

So what can parents do to teach children to be better health decision-makers? Cohen suggests:

--Confer and collaborate with teachers to find out what is happening at your child’s school. A partnership between parents and teachers helps to support our complementary goals for children, to further their healthy development.

--Think about the fundamental question: What are the skills, knowledge and attitudes that matter most to us? Reflecting on that question gets parents away from the usual anxiety around grades and other concerns. Instead, it invites parents to think about how they can help their children become responsible, learn, form friendships, solve problems and become creative thinkers. This is a powerful step parents can take, but it also requires that adults recognize where a child is from a developmental perspective.

--Become role models. Because kids often mimic the behaviors they see, parents need to show children how we confront challenges, solve problems and how we deal with troubling situations. "Often our kids have the misimpression that we solve things automatically," Cohen says, adding that parents need to share with their kids how they arrive at decisions or meet challenges, making sure that this lesson is age appropriate. What are the steps that you take to think about the nature of a problem or decision? How do you set a goal? How do you figure out which strategy makes sense? What do you do when you get stuck? And, how do you evaluate how your strategy has worked or not?

--Teach social and emotional literacy. "As important as it is to read books to kids, it’s equally important to ‘read’ ourselves and others," Cohen says. Children’s ability to understand and interpret their feelings and those of others is important to their ability to deal appropriately with these feelings.

--Look for teachable moments, when inappropriate behavior can be redirected into a positive lesson. For example, parents dealing with a child who repeatedly misbehaves at the dinner table need to address the child’s problem and set limits. Problems are almost always opportunities. However, parents can also help the child understand ways for her to stop the problem behavior. Parents can point out situations where they themselves felt stuck. Also, parents can convene a family meeting focused on how family members treat one another.

Peer Pressure and Other Environmental Influences

Peer pressure can often influence children to do things they would not otherwise do. During adolescence, when many health-related habits are formed, (3,9) peer pressure is more likely to have a negative influence than a positive one.

However, numerous studies of programs incorporating social and emotional learning have found that peer pressure can be a positive force in keeping kids from drinking, using drugs, practicing unsafe sex and engaging in other unhealthy behaviors. University of Minnesota researcher Cheryl Perry found that the negative effect of peer pressure for adolescents could be transformed so that it’s a catalyst for positive change.

A successful alcohol prevention program Perry studied "had a positive impact on the peer culture," she said. (See CASE STUDY: Project Northland Improves Teen Alcohol, Smoking Rates). That program depended on peer-led activities in 7^th-grade classrooms to help instill and reinforce the consequences of youth drinking. But peer pressure is just one of the environmental influences challenging kids. Media messages, advertising, school environments, stress and other environmental factors influence youths’ decisions about risky health behaviors.

"In a media-savvy world, the environment has become very important in terms of its impact on children’s behavior," Perry says.

Moreover, the school environment sends subtle yet powerful messages to children, Perry says. Unlike today, when most schools have zero tolerance for smoking on school grounds, a few years ago that was not the case. In fact, many public high schools around the nation set aside smoking areas for students. Today, though, school districts have made revenue-generating decisions to outfit their places of learning with junk food and soda machines. "Think of that in terms of norms," Perry says. "Kids are less likely to drink [healthy beverages]."

Numerous other factors in the school environment also affect behavior, Perry says, including whether a friendly atmosphere exists toward non-athletes and to females, or whether the school is open late for extracurricular activities. Even the physical layout of the school, and the age and condition of desks and equipment create a set of messages. For example, is the school perceived as a central component of the community and a safe place to be, or is it viewed more like a storefront in which school is only opened during the six hours of classes and locked up right afterward?

The Research:

1. Botvin, G.J., Baker, E., Botvin, E.M., Filazzola, A.D., & Millman, R.B. (1984). Prevention of alcohol misuse through the development of personal and social competence: A pilot study. Journal of Studies on Alcohol, 45, 550-552.

2. Centers for Disease Control and Prevention. (1998). Health related quality of life and activity limitation: Eight states, 1995. Morbidity and Mortality Weekly Report, 47, 134-140.

3. Crockett, L.J. & Crouter, A.C. (1995). Pathways through adolescence: Individual development in relation to social contexts. Mahwah, N.J.: Lawrence Erlbaum Associates.

4. Chassin, L., Presson, C.C., Sherman, S.J., & McConnell, A.R. (1995). Adolescent health issues. In M.C. Roberts (Ed), Handbook of pediatric psychology (2nd ed., pp.723-740). New York: Guilford Press.

5. Dryfoos, J.G. (1997). The prevalence of problems behaviors: Implications for programs. In R.P. Weissberg, T.P. Gullotta, R.L. Hampton, B.A. Ryan, & G..R. Adams (Eds), Healthy children 2010: Enhancing children’s wellness (pp. 17-46). Thousand Oaks, CA: Sage.

6. Jessor, R. (1987). Problems behavior theory, psychosocial development, and adolescent problem drinking. British Journal of Addiction, 82, 331-342.

7. Kim, N., Stanton, B, Li, X., Dickersin, K., & Galbraith, J. (1997). Effectiveness of 40 adolescent AIDS risk reduction interventions: A quantitative review. Journal of Adolescent Health, 20, 204-215.

8. McGinnis, J.M., & Foege, W.H. (1993). Actual causes of death in the United States. Journal of the American Medical Association, 270, 2707-2212.

9. Millstein, S.G., Petersen, A.C., & Nightingale, E.O. (1993). Promoting the health of adolescents: New directions for the twenty-first century. New York: Oxford University Press.

10. Centers for Disease Control and Prevention. (2000). National and state-specific pregnancy rates among adolescents—United States, 1995-1997. Morbidity and Mortality Weekly Report, 49, 605-611.

11. Centers for Disease Control and Prevention. (2000). Tracking the Hidden Epidemic: Trends in STDs in the United States 2000.

Available: http://www.cdc.gov/nchstp/dstd/Stats_Trends/Trends2000.pdf

12^. Perry, C.L., Williams, C.L., Veblen-Mortenson, S., Toomey, T.L., Komro, K.A., Anstine, P.S., McGovern, P. G., Finnegan, J.R., Forster, J. L., Wagenaar, A.C, & Wolfson, M. (1996). Project Northland: Outcomes of a community-wide alcohol use prevention program during early adolescence. American Journal of Public Health, 86( 7), pp. 956-965.

13. U.S. Congress, Office of Technology Assessment and Adolescent Health. (1991). Summary of Policy Options, Vol. 1. (Publication No. OTA h-468). Washington, DC: US Government Printing Office.

14. U.S. Department of Health and Human Services. (1990). Healthy People 2000: National Health Promotion and Disease Prevention Objectives (Publication No. (PHS) 91-50212). Washington, DC.

15. Center for Disease Control and Prevention (1997). Youth Risk Behavior Surveillance – United States, 1997. Morbidity and Mortality Weekly Report, 47 (No. SS-3).

16. National Institute on Alcohol Abuse and Alcoholism. (2000). How to make a difference: Talk to your children about alcohol. Available: http://silk.nih.gov/silk/niaaa1/publication/children.pdf

17. The Collaborative to Advance Social and Emotional Learning and the Center for Advancement of Health. (unpublished). Social-emotional competence and physical health. Washington, DC: Wallander, J.L.

18. Weissberg, R. P., Barton, H. A., & Shriver, T. P. (1997). The Social-Competence Promotion Program for Young Adolescents. In G. W. Albee & T. P. Gullotta (Eds.), Primary prevention exemplars: The Lela Rowland Awards (pp. 268-290). Thousand Oaks, CA: Sage.

19. Tobler, N.S., & Stratton, H.H. (1997). Effectiveness of school-based drug prevention programs: A meta-analysis of the research. Journal of Primary Prevention, 18, 71-128.

20. Elias, M. J., Zins, J. E., Weissberg, R. P., Frey, K. S., Greenberg, M. T., Haynes, N. M., Kessler, R., Schwab-Stone, M. E., & Shriver, T. P. (1997). Promoting social and emotional learning: Guidelines for educators. Alexandria, VA: Association for Supervision and Curriculum Development.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

For Information Contact:
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Center for the Advancement of Health
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