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• W2023367538 abstract "See Related Article p. 525Visits to the doctor have often focused on what is wrong with an adolescent. Converging fields of study suggest that we should also be focusing on what is right [1Seligman M.E. Steen T.A. Park N. et al.Positive psychology progress: Empirical validation of interventions.Am Psychol. 2005; 60: 410-421Crossref PubMed Scopus (2906) Google Scholar, 2Resnick M.D. Bearman P.S. Blum R.W. et al.Protecting adolescents from harm Findings from the National Longitudinal Study on Adolescent Health.JAMA. 1997; 278: 823-832Crossref PubMed Google Scholar, 3Catalano R.F. Hawkins J.D. Berglund M.L. et al.Prevention science and positive youth development: competitive or cooperative frameworks?.J Adolesc Health. 2002; 31: 230-239Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar]. Practice guidelines reflect this approach by including recommendations to remind adolescents and families about strengths, as well as to screen for risky health behaviors [4Green M. Palfrey J.S. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. National Center for Education in Maternal and Child Health, Georgetown University, Arlington, Virginia2002Google Scholar, 5Elster A.B. Kuznets N. AMA Guidelines for Adolescent Preventive Services: Recommendations and Rationale. Williams & Wilkins, Baltimore, Maryland1994Google Scholar].Guidelines have provided an essential framework for delivering care to adolescents, yet clinicians and health care systems have often lacked realistic models for integrating these services. Lower than recommended levels of screening [[6]Rand C.M. Auinger P. Klein J.D. et al.Preventive counseling at adolescent ambulatory visits.J Adolesc Health. 2005; 37: 87-93Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar] have prompted the development of primary care interventions that have been successful at increasing the screening of adolescents for risky health behaviors [7Irwin Jr, C.E. Clinical preventive services for adolescents: Still a long way to go.J Adolesc Health. 2005; 37: 85-86Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 8Tylee A. Haller D.M. Graham T. et al.Youth-friendly primary-care services: How are we doing and what more needs to be done?.Lancet. 2007; 369: 1565-1573Abstract Full Text Full Text PDF PubMed Scopus (461) Google Scholar]. There has been far less emphasis on how to integrate strength-based approaches into the care of adolescents.The article by Duncan et al in this issue of the Journal provides both a theoretical justification and a clinical model for incorporating a strength-based approach into primary care. The authors describe the goals of a strength-based approach as raising adolescents’ awareness of their developing strengths and motivating them to take responsibility for the role they can play in their own health and well-being. Duncan et al review strength-based concepts as used in research, policy, and program development, and then propose a clinical approach that reflects the integration of the fields of prevention science and positive youth development. Focusing on decreasing risky behavior and enhancing protective factors is likely to affect both problem and positive behaviors, promoting better outcomes for youth [[3]Catalano R.F. Hawkins J.D. Berglund M.L. et al.Prevention science and positive youth development: competitive or cooperative frameworks?.J Adolesc Health. 2002; 31: 230-239Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar]. Consistent with this approach to strength-promotion has been a focus on developmental assets that can foster healthy development and prevent risky behavior [[9]Leffert N. Benson P.L. Scales P.C. Measurement and prediction of risk behaviors among adolescents.Appl Dev Sci. 1998; 2: 209-230Crossref Scopus (356) Google Scholar].Duncan et al deserve recognition for skillfully combining a review paper with real-life clinical guidance. They provide a detailed clinical model of how features of positive developmental settings can be incorporated into the medical office environment, and how a strength-based approach that emphasizes assets can become part of the familiar clinical interview. Here I build upon several points raised by the authors.First, the authors make the important point that an office visit is not just a time to assess strengths but also a time to promote strengths. The process of how to promote adolescent strengths deserves further discussion. Examples of how to reinforce competencies by asking about or pointing out a teen’s strengths is described extensively in the article. However, consistent with models that integrate positive and problem behavior, a focus on strengths can also be systematically integrated into risk reduction inquiry.In our own work on developing models to increase screening and counseling for risky health behaviors [10Ozer E.M. Adams S.H. Lustig J.L. et al.Can it be done? Implementing adolescent clinical preventive services.Health Serv Res. 2001; 36: 150-165PubMed Google Scholar, 11Ozer E.M. Adams S.H. Lustig J.L. et al.Increasing the screening and counseling of adolescents for risky health behaviors: A primary care intervention.Pediatrics. 2005; 115: 960-968Crossref PubMed Scopus (127) Google Scholar], clinicians were prompted to reinforce positive behavior as well as to build on success experiences when discussing risky behavior. For example, if a teenager was consistently wearing a seatbelt, she received positive reinforcement for keeping herself safe. If a sexually active teenager was having difficulty regularly using condoms, he might be asked about when he was last able to use a condom, thereby shifting the emphasis to understanding what circumstances enabled him to be successful [[12]Ozer M.N. The character of the solution.in: Ozer M.N. The Management of Persons with Chronic Neurological Illness. Butterworth-Heinenmann, Boston, Massachusetts2000Google Scholar].Second, to enhance strengths in adolescents, we need to provide opportunities for clinicians to increase their competence to deliver strength promotion to adolescents. We know that clinician self-efficacy is related to the delivery of services to teenagers [[13]Ozer E.M. Adams S.H. Gardner L.R. et al.Provider self-efficacy and the screening of adolescents for risky health behaviors.J Adolesc Health. 2004; 35: 101-107Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar], and that clinician training increases preventive screening and counseling [14Lustig J.L. Ozer E.M. Adams S.H. et al.Improving the delivery of adolescent clinical preventive services through skills-based training.Pediatrics. 2001; 107: 1100-1107Crossref PubMed Scopus (76) Google Scholar, 15Klein J.D. Allan M.J. Elster A.B. et al.Improving adolescent preventive care in community health centers.Pediatrics. 2001; 107: 318-327Crossref PubMed Scopus (103) Google Scholar]. In addition, prior work that involved training providers in the strength-based approach resulted in significant increases in youth screened for the assets of generosity, independence, mastery, and belonging [[16]Duncan P.M. Garcia A.C. Frankowski B.L. et al.Inspiring healthy adolescent choices: A rationale for and guide to strength promotion in primary care.J Adolesc Health. 2007; 41: 525-535Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar].Third, we need to integrate what has been learned from increasing screening about risk-taking to increasing strength-based promotion. Providing guideline information is not enough. If clinicians are going to focus on assets, they require information that is targeted, easily usable, and fully integrated into the clinic office or health care system. The clinical practices participating in the Vermont Youth Improvement Initiative, described in the review paper by Duncan et al, use a reminder sticker attached to patient charts to ask about and track six risk behaviors, plus four assets. The areas are clear and brief, and the sticker serves as a consistent reminder. If strength-based approaches are going to be integrated into the care of adolescents, strength assessment items need to be incorporated into adolescent screening questionnaires, prompts and cues on charting forms, and health care quality measures.Finally, more research is needed on the behavioral and health outcomes of brief office-based interventions with adolescents. Our recent work suggests that a pediatric primary care intervention with a strong focus on increasing adolescents’ efficacy to make healthy decisions resulted in positive behavioral outcomes across multiple risk areas [[17]Ozer E.M. Adams S.H. Orrell-Valente J. et al.Does Screening and Counseling Adolescents Influence Their Behavior?.Pediatr Res. 2004; 55 (Abstract): 2AGoogle Scholar]. In addition to evaluating the outcome of particular risk areas, future work could include strength-based outcomes such as effectively using the health care system, taking increased responsibility for one’s health, and engaging in positive health behavior (not simply the absence of risk). Furthermore, more knowledge is needed on the outcome of a teen discussing assets or strengths with a clinician during an office visit.Linked to developing evidence-based strength outcomes is the growing field of positive psychology, an umbrella term for the study of positive emotions, positive character traits, and enabling institutions [[1]Seligman M.E. Steen T.A. Park N. et al.Positive psychology progress: Empirical validation of interventions.Am Psychol. 2005; 60: 410-421Crossref PubMed Scopus (2906) Google Scholar]. This new field builds on long-standing strength-based models, such as social cognitive theory, with its emphasis on self-efficacy as a determinant of optimal human functioning [[18]Bandura A. Self-efficacy mechanism in human agency.Am Psychol. 1982; 37: 122-147Crossref Scopus (8730) Google Scholar]. More recently, Seligman et al have developed a clinical classification for strengths and virtues that enable human thriving [[1]Seligman M.E. Steen T.A. Park N. et al.Positive psychology progress: Empirical validation of interventions.Am Psychol. 2005; 60: 410-421Crossref PubMed Scopus (2906) Google Scholar]. In related work, they found that simple exercises—such as practicing using strengths and writing down what went well every day for 1 week—increased happiness and decreased depressive symptoms. Primary care interventions can use this research by integrating empirically validated, strength-based approaches into the office setting.Converging fields of study are emphasizing a shift toward strength-based approaches. Now is the time to incorporate strength promotion into adolescent primary care. Emphasizing strengths does not have to be an “add-on” to the clinical visit but, rather, a rethinking of the way in which we work with teenagers. Primary care clinicians have multiple opportunities to positively influence the health of teenagers. This article provides a model for building upon what is right. See Related Article p. 525 See Related Article p. 525 See Related Article p. 525 Visits to the doctor have often focused on what is wrong with an adolescent. Converging fields of study suggest that we should also be focusing on what is right [1Seligman M.E. Steen T.A. Park N. et al.Positive psychology progress: Empirical validation of interventions.Am Psychol. 2005; 60: 410-421Crossref PubMed Scopus (2906) Google Scholar, 2Resnick M.D. Bearman P.S. Blum R.W. et al.Protecting adolescents from harm Findings from the National Longitudinal Study on Adolescent Health.JAMA. 1997; 278: 823-832Crossref PubMed Google Scholar, 3Catalano R.F. Hawkins J.D. Berglund M.L. et al.Prevention science and positive youth development: competitive or cooperative frameworks?.J Adolesc Health. 2002; 31: 230-239Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar]. Practice guidelines reflect this approach by including recommendations to remind adolescents and families about strengths, as well as to screen for risky health behaviors [4Green M. Palfrey J.S. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. National Center for Education in Maternal and Child Health, Georgetown University, Arlington, Virginia2002Google Scholar, 5Elster A.B. Kuznets N. AMA Guidelines for Adolescent Preventive Services: Recommendations and Rationale. Williams & Wilkins, Baltimore, Maryland1994Google Scholar]. Guidelines have provided an essential framework for delivering care to adolescents, yet clinicians and health care systems have often lacked realistic models for integrating these services. Lower than recommended levels of screening [[6]Rand C.M. Auinger P. Klein J.D. et al.Preventive counseling at adolescent ambulatory visits.J Adolesc Health. 2005; 37: 87-93Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar] have prompted the development of primary care interventions that have been successful at increasing the screening of adolescents for risky health behaviors [7Irwin Jr, C.E. Clinical preventive services for adolescents: Still a long way to go.J Adolesc Health. 2005; 37: 85-86Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 8Tylee A. Haller D.M. Graham T. et al.Youth-friendly primary-care services: How are we doing and what more needs to be done?.Lancet. 2007; 369: 1565-1573Abstract Full Text Full Text PDF PubMed Scopus (461) Google Scholar]. There has been far less emphasis on how to integrate strength-based approaches into the care of adolescents. The article by Duncan et al in this issue of the Journal provides both a theoretical justification and a clinical model for incorporating a strength-based approach into primary care. The authors describe the goals of a strength-based approach as raising adolescents’ awareness of their developing strengths and motivating them to take responsibility for the role they can play in their own health and well-being. Duncan et al review strength-based concepts as used in research, policy, and program development, and then propose a clinical approach that reflects the integration of the fields of prevention science and positive youth development. Focusing on decreasing risky behavior and enhancing protective factors is likely to affect both problem and positive behaviors, promoting better outcomes for youth [[3]Catalano R.F. Hawkins J.D. Berglund M.L. et al.Prevention science and positive youth development: competitive or cooperative frameworks?.J Adolesc Health. 2002; 31: 230-239Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar]. Consistent with this approach to strength-promotion has been a focus on developmental assets that can foster healthy development and prevent risky behavior [[9]Leffert N. Benson P.L. Scales P.C. Measurement and prediction of risk behaviors among adolescents.Appl Dev Sci. 1998; 2: 209-230Crossref Scopus (356) Google Scholar]. Duncan et al deserve recognition for skillfully combining a review paper with real-life clinical guidance. They provide a detailed clinical model of how features of positive developmental settings can be incorporated into the medical office environment, and how a strength-based approach that emphasizes assets can become part of the familiar clinical interview. Here I build upon several points raised by the authors. First, the authors make the important point that an office visit is not just a time to assess strengths but also a time to promote strengths. The process of how to promote adolescent strengths deserves further discussion. Examples of how to reinforce competencies by asking about or pointing out a teen’s strengths is described extensively in the article. However, consistent with models that integrate positive and problem behavior, a focus on strengths can also be systematically integrated into risk reduction inquiry. In our own work on developing models to increase screening and counseling for risky health behaviors [10Ozer E.M. Adams S.H. Lustig J.L. et al.Can it be done? Implementing adolescent clinical preventive services.Health Serv Res. 2001; 36: 150-165PubMed Google Scholar, 11Ozer E.M. Adams S.H. Lustig J.L. et al.Increasing the screening and counseling of adolescents for risky health behaviors: A primary care intervention.Pediatrics. 2005; 115: 960-968Crossref PubMed Scopus (127) Google Scholar], clinicians were prompted to reinforce positive behavior as well as to build on success experiences when discussing risky behavior. For example, if a teenager was consistently wearing a seatbelt, she received positive reinforcement for keeping herself safe. If a sexually active teenager was having difficulty regularly using condoms, he might be asked about when he was last able to use a condom, thereby shifting the emphasis to understanding what circumstances enabled him to be successful [[12]Ozer M.N. The character of the solution.in: Ozer M.N. The Management of Persons with Chronic Neurological Illness. Butterworth-Heinenmann, Boston, Massachusetts2000Google Scholar]. Second, to enhance strengths in adolescents, we need to provide opportunities for clinicians to increase their competence to deliver strength promotion to adolescents. We know that clinician self-efficacy is related to the delivery of services to teenagers [[13]Ozer E.M. Adams S.H. Gardner L.R. et al.Provider self-efficacy and the screening of adolescents for risky health behaviors.J Adolesc Health. 2004; 35: 101-107Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar], and that clinician training increases preventive screening and counseling [14Lustig J.L. Ozer E.M. Adams S.H. et al.Improving the delivery of adolescent clinical preventive services through skills-based training.Pediatrics. 2001; 107: 1100-1107Crossref PubMed Scopus (76) Google Scholar, 15Klein J.D. Allan M.J. Elster A.B. et al.Improving adolescent preventive care in community health centers.Pediatrics. 2001; 107: 318-327Crossref PubMed Scopus (103) Google Scholar]. In addition, prior work that involved training providers in the strength-based approach resulted in significant increases in youth screened for the assets of generosity, independence, mastery, and belonging [[16]Duncan P.M. Garcia A.C. Frankowski B.L. et al.Inspiring healthy adolescent choices: A rationale for and guide to strength promotion in primary care.J Adolesc Health. 2007; 41: 525-535Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar]. Third, we need to integrate what has been learned from increasing screening about risk-taking to increasing strength-based promotion. Providing guideline information is not enough. If clinicians are going to focus on assets, they require information that is targeted, easily usable, and fully integrated into the clinic office or health care system. The clinical practices participating in the Vermont Youth Improvement Initiative, described in the review paper by Duncan et al, use a reminder sticker attached to patient charts to ask about and track six risk behaviors, plus four assets. The areas are clear and brief, and the sticker serves as a consistent reminder. If strength-based approaches are going to be integrated into the care of adolescents, strength assessment items need to be incorporated into adolescent screening questionnaires, prompts and cues on charting forms, and health care quality measures. Finally, more research is needed on the behavioral and health outcomes of brief office-based interventions with adolescents. Our recent work suggests that a pediatric primary care intervention with a strong focus on increasing adolescents’ efficacy to make healthy decisions resulted in positive behavioral outcomes across multiple risk areas [[17]Ozer E.M. Adams S.H. Orrell-Valente J. et al.Does Screening and Counseling Adolescents Influence Their Behavior?.Pediatr Res. 2004; 55 (Abstract): 2AGoogle Scholar]. In addition to evaluating the outcome of particular risk areas, future work could include strength-based outcomes such as effectively using the health care system, taking increased responsibility for one’s health, and engaging in positive health behavior (not simply the absence of risk). Furthermore, more knowledge is needed on the outcome of a teen discussing assets or strengths with a clinician during an office visit. Linked to developing evidence-based strength outcomes is the growing field of positive psychology, an umbrella term for the study of positive emotions, positive character traits, and enabling institutions [[1]Seligman M.E. Steen T.A. Park N. et al.Positive psychology progress: Empirical validation of interventions.Am Psychol. 2005; 60: 410-421Crossref PubMed Scopus (2906) Google Scholar]. This new field builds on long-standing strength-based models, such as social cognitive theory, with its emphasis on self-efficacy as a determinant of optimal human functioning [[18]Bandura A. Self-efficacy mechanism in human agency.Am Psychol. 1982; 37: 122-147Crossref Scopus (8730) Google Scholar]. More recently, Seligman et al have developed a clinical classification for strengths and virtues that enable human thriving [[1]Seligman M.E. Steen T.A. Park N. et al.Positive psychology progress: Empirical validation of interventions.Am Psychol. 2005; 60: 410-421Crossref PubMed Scopus (2906) Google Scholar]. In related work, they found that simple exercises—such as practicing using strengths and writing down what went well every day for 1 week—increased happiness and decreased depressive symptoms. Primary care interventions can use this research by integrating empirically validated, strength-based approaches into the office setting. Converging fields of study are emphasizing a shift toward strength-based approaches. Now is the time to incorporate strength promotion into adolescent primary care. Emphasizing strengths does not have to be an “add-on” to the clinical visit but, rather, a rethinking of the way in which we work with teenagers. Primary care clinicians have multiple opportunities to positively influence the health of teenagers. This article provides a model for building upon what is right. Inspiring Healthy Adolescent Choices: A Rationale for and Guide to Strength Promotion in Primary CareJournal of Adolescent HealthVol. 41Issue 6PreviewThe social, emotional, and biological health of adolescents requires their development as autonomous beings who make responsible decisions about their own health. Clinicians can assist in this development by adopting a strength-based approach to adolescent health care, which applies concepts from positive youth development to the medical office setting. Full-Text PDF" @default.
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