Positive Adolescent Life Skills Training for High-Risk Teens: Results of a Group Intervention Study

Abstract

Introduction

This study tested the addition of a cognitive-behavioral skill-building component called Positive Adolescent Life Skills (PALS) training to an existing intervention for urban adolescents to enhance resiliency. In previous pilot work with the existing intervention, called “Teen Club,” it was found that participants in group meetings and intensive case management reported an enhanced ability to connect with positive resources.

Method

Sixteen adolescents aged 12 to 16 years (10 boys and 6 girls) attending an urban secondary school were randomly assigned to Teen Club or Teen Club plus PALS. Boys and girls met separately in one of the two conditions for 30 weeks. The Problem-Oriented Screening Instrument for Teenagers (POSIT) subscale scores were measured at baseline and at the completion of the program.

Results

The sample consisted of 11 Black and five Hispanic teens. Between-group differences in the POSIT subscale scores were not significantly different in this small sample. Group interviews conducted at the conclusion of the intervention revealed that participants found the PALS intervention to be relevant and useful.

Discussion

Results suggest that the PALS component strengthened the existing intervention and lend preliminary support for the continuation of this combination of interventions. Future research with larger numbers is needed.

Healthy adolescent development and the avoidance of risk-taking behavior are enhanced by attachment with caring adults. Most teens look to their families to provide them with resiliency factors such as support, positive role modeling, and a sense of themselves as worthy of care. Adolescents living in families impaired by drug and alcohol abuse, mental health problems, violence, and poverty may find it more difficult to access these resiliency factors and therefore are more vulnerable to risk-taking behavior. Children of parents who are impaired by substance abuse, mental health problems, and violence are at increased risk for developing similar problems and other related adverse health outcomes (Weissman et al., 1999).

In the National Longitudinal Study of Adolescent Health (Resnick et al., 1997) it was found that when teens felt connected to their families and schools, they reported less risk-taking behavior, including decreased use of cigarettes, alcohol, and marijuana. Protective factors were associated with opportunities for teens to see caring adults role modeling conventional behaviors in the home and community. Although family support during adolescence also tends to protect against drug use and its consequences (Tuttle, 1995), the teens at highest risk frequently lack positive individual, family, neighborhood, and community resources and adult role models. The study reported in this article was designed to enhance teen resilience by supporting the development of social skills needed to make positive connections and overcome the influence of negative parental norms (Campbell-Heider, Tuttle, Bidwell-Cerone, Richeson, & Collins, 2003). The acquisition of skills that improve communication and enhance the social network of adolescents should reduce the propensity for health risk behaviors such as alcohol and other drug use.

This article describes the development, implementation, and testing of a 30-week intervention program to enhance resiliency in young high risk teens attending and urban secondary school. Specifically, the Positive Adolescent Life Skills (PALS) training curriculum (Hall, Richardson, Spears, & Grinstead, 1996) was added to an existing community-based nursing intervention called “Teen Club,” which has shown promise in reducing risk-taking behaviors in poor, urban, minority adolescents (Tuttle, Bidwell-Cerone, Campbell-Heider, Richeson, & Collins, 2000). This pilot study was conducted to determine the effects of the two types of group interventions on teenage risk-taking behaviors. A secondary aim of the study was to determine the cultural relevancy of the PALS skill training in a poor, urban, minority teen population. This article reports on the pre-intervention and immediate post-intervention test findings of this study.

INITIAL DEVELOPMENT OF THE “TEEN CLUB” INTERVENTION

The initial Teen Club nursing intervention was developed in 1992 in response to needs recognized among inner-city teens attending an urban Community Health Center’s Teen Clinic. Their chaotic family and social environments included violence, poverty, and substance abuse. A community health nurse (CHN) and community outreach worker created the group intervention to provide additional social support, health education, community outreach, and instrumental assistance to these high-risk teens (Tuttle et al., 2000). Teens participated on a weekly basis for an average of 2 years.

Preliminary data suggest that 5 years after their initial involvement, female graduates of the first “Teen Club” cohort (n = 12) had more workforce participation, greater school completion, fewer pregnancies, and less depression compared with 12 similar adolescents who did not receive the intervention (Tuttle, Campbell-Heider, Bidwell-Cerone, Richeson, & Collins, 2001). A third preliminary study using concept mapping techniques determined that Teen Club participants perceived connections to group leaders as most helpful (Campbell-Heider et al., 2003). These studies suggested that the Teen Club intervention was providing needed support to high-risk teens but might benefit from an intervention component that formally addressed drug and alcohol prevention.

PALS TRAINING

The cognitive-behavioral theory that underlies PALS suggests that health risk behavior can be modified by teaching skills for behavioral change (Botvin & Botvin, 1992). This notion also corresponds to the literature that suggests a teen’s positive connectedness with the family, social, and community environment is protective against substance abuse (Resnick et al., 1997). The PALS training program is a cognitive-behavioral, skill-building intervention that has shown promise in improving social skills in a general population of mainly White 8th graders in a rural environment (Hall, Richardson, Spears, & Grinstead, 1996). It contains 25 cognitive-behavioral skill-building sessions that are divided into five modules. The program was tested on a rural sample of 146 eighth graders. Post-intervention scores indicated significant improvements in mean scores on the Iowa Social Skills Improvement Test for problem solving, communication, handling criticism, and saying “no” to high-risk behavior subscales.

Another study of white, middle-class, rural teens (Richardson, Hall, Spears, & Weeks, 1996) found gender differences in the effectiveness of PALS training for eighth graders. Girls made greater improvements shortly after the intervention in social competence for assertiveness in refusing high-risk behavior and handling criticism. At the 1-year follow-up, boys’ improvement exceeded the girls’ improvement only in handling criticism. The other gender differences in social competence persisted.

The addition of PALS training is intended to augment the acquisition of behavioral skills that support adolescents’ ability to make positive connections with their social environments and avoid risky behaviors such as substance abuse. The present study was designed to test the effectiveness of PALS in a sample of urban, minority adolescents and to obtain preliminary information about gender differences in outcomes and retention rates. It also was intended to provide feedback from participants about the acceptability and cultural relevance of PALS training.

METHOD

Once institutional review board and school district approval was obtained, adolescents between 12 and 16 years of age were recruited at a large urban secondary school. In order to participate, teens needed to be able to speak and understand English. Exclusion criteria included diagnoses of developmental delay, such as teens enrolled in a self-contained special education program (as opposed to merely receiving special education services), and previous participation in “Teen Club.”

Of the 39 students who indicated interest, only 18 were able to provide both parental consent and teen assent to participate. These adolescents were randomly assigned by gender to one of two conditions: conventional “Teen Club” or “Teen Club” plus PALS. Shortly after the study began, two students dropped out. One was placed on long-term suspension and the other had a schedule conflict that kept her from attending. The remaining 16 adolescents (10 boys and six girls) participated in group meetings and activities. These meetings and activities were held separately for each condition to minimize contamination between the groups. The two conditions (four separate groups) were implemented during the same period (the 2003–2004 school year) and for the same number of weeks (30) to reduce threats to internal validity such as history and maturation.

The group meetings were held after school in a large meeting room at the school. Transportation home after the group meetings was provided, and group leaders were available between meetings for support and case management. There was no significant difference between any of the groups in terms of numbers of sessions attended (mean = 27 out of 30 weeks).

INTERVENTIONS

All teens participated in weekly group meetings. Healthy snacks were served at the beginning of each meeting, and transportation home was provided. There were no structured cognitive behavioral life skills training in the Teen Club–only condition. Teen Club plus PALS subjects participated in 25 cognitive behavioral skill-building sessions divided into five modules. Box 1 outlines the content of both conditions over the 30-week intervention phase.

BOX 1.

Study protocol

	Comparison Group “Teen Club”	Experimental Group “Teen Club” Plus PALS
Unit I	Information exchange	Basic communication skills
Week 1	Introduction, pretest	Introduction, assertion, pretest
Week 2	Setting goals	Assertive listening
Week 3	Dealing with anger	Positive feedback & praise
Week 4	Using respect & manners	Negative feedback & criticism
Week 5	Communicating with peers	Unit Review Evaluation, practice with communication skills
Week 6	Activity as incentive	Activity as incentive
Unit II	Information about relationships	Social network skills
Week 7	Families’ responses to addiction	Introduction to social networks—family, what is positive support?
Week 8	Teens’ roles in the community	School and community as social networks, what is negative support?
Week 9	Healthy dating relationships	Network change skills 1. Increasing positive support
Week 10	Choosing friends	Network change skills 2. Decreasing negative support
Week 11	Checking in regarding goals	Unit review & evaluation. Practice with network skills, changing your network
Week 12	Activity as incentive	Activity as incentive
Unit III	Information about high-risk behaviors	Saying NO to high risk behaviors
Week 13	Effects of alcohol & tobacco	Dealing with alcohol & tobacco
Week 14	Effects of marijuana, cocaine, etc	Dealing with marijuana, cocaine, etc.
Week 15	Legal status of adolescents	Dealing with delinquent behaviors
Week 16	HIV & AIDS	Dealing with sexual harassment & assault
Week 17	Keeping safe	Unit review & evaluation. Can you use these skills?
Week 18	Activity as incentive	Activity as incentive
Unit IV	Information about self-esteem	Handling aggressive criticism
Week 19	Identity formation	Handling criticism from a parent
Week 20	Resources for extra help at school	Handling criticism from a teacher or other school authority
Week 21	Why do teenagers “pick on” others?	Handling criticism from a peer
Week 22	Healthy activities for teenagers	Handling criticism from a best friend or “partner”
Week 23	Community volunteerism	Unit review & evaluation. Can you use these skills?
Week 24	Activity as incentive	Activity as incentive
Unit V	Information about decision making	Dealing with uncomfortable feelings with problem solving
Week 25	Decision-making styles	Dealing with drug use at a party
Week 26	Cost-benefit analysis	Dealing with disappointment & failure
Week 27	Identifying depression	Dealing with depression & feeling down
Week 28	Sexual decision making	Dealing with peer pressure & being yourself
Week 29	Checking in regarding goals, posttest	Unit review & evaluation, can you use these skills? Posttest
Week 30	Activity as incentive	Activity as incentive

The PALS behavioral skill training focused on basic communication and was designed to enhance the teens’ ability to listen, negotiate, and handle criticism through role playing and behavioral rehearsal. The network skill content was directed toward enhancing social support through positive participation in the social environment. The cognitive skill content teaches problem-solving skills for dealing with challenging situations. These modules formed the focus of the weekly meetings in this group. Both programs met for 1½ hours per week.

At least one leader in each group was a registered nurse. The community health nurse who founded “Teen Club” trained all group leaders in “Teen Club” techniques. A consultant with experience in using the PALS intervention trained the group leaders assigned to the experimental groups. PALS group leaders were given training manuals, and the participants all had PALS workbooks. To ensure the integrity of the intervention, the investigators periodically reviewed a random selection of session audio recordings and directly observed each group.

All groups participated in incentive activities every sixth week. Teens who had attended at least 4 of the 5 previous weeks’ sessions chose group activities, such as playing basketball at a local university or attending a movie in the community. Points also were given for attending group sessions and completing the study instruments. These points were exchanged for mall gift certificates at the end of the year.

To effectively execute the study protocols, experienced adult group leaders were used to facilitate the discussions at each group meeting and incentive activity. The group leaders were both male and female adults between the ages of 22 and 45 years. These adults were familiar with the participants’ school system, neighborhoods, and community recreation, religious, and social organizations. Using adult facilitators who were familiar with and connected to the communities in which the participants lived may have helped with getting the participants to disclose real-life experiences that had relevance to the topics discussed at each group meeting (Teen Club) and behavioral skill-building session (Teen Club plus PALS). Additionally, using facilitators who were connected to the participants’ communities may have helped with gaining the participants’ trust and respect and with retaining the participants in this study.

The four black leaders requested that the teens use formal titles of Ms, Miss, or Mr. when addressing the leaders during the group sessions. This situation seemed to set the tone for increased boundaries between the young teens and adult leaders that reinforced the notion that the leaders were not “peers.” The Black leaders reported that this approach helped to maintain control of the groups in terms of acceptable behaviors, acceptable conversation, and acceptable use of terms that illustrate sexual or risky behaviors. Group leaders also noted that this control of behaviors was evident in the group activities sessions. The one White leader did not insist on formal titling and did not comment on this issue in her group report. However, in listening to group tapes and visiting the groups, it appeared that the Black leaders were in better control over the teens than was the White leader. Obviously, this situation also could be a result of other leadership style issues or the congruency in cultural identity that the Black group leaders had with the minority teens. In any case, these leadership issues will need more study in future intervention groups, because maintaining control of the group is an important process consideration.

MEASURES

The study’s dependent variables consisted of indicators of risk-taking behavior in adolescents. These behaviors are operationalized by the Problem Oriented Screening Instrument for Teenagers (POSIT) subscales: (a) Substance Abuse; (b) Physical Health; (c) Mental Health; (d) Family Relationships; (e) Peer Relationships; (f) Educational Status; (g) Vocational Status; (h) Social Skills;(i) Leisure/Recreation; and (j) Aggressive Behavior/Delinquency. The POSIT is a self-report measure of 139 items at a fifth-grade reading level and is available in English and Spanish (Winters, 1999). It has been used widely in both clinical practice and research (Rahdert, 1991). Examples of items include: “Do your friends get bored at parties when there is no alcohol or drugs served?” (substance abuse), and “Do you and your parents or guardians do lots of things together?” (family relationships). Evidence for the validity of the instrument is well established (Knight, Goodman, Pulerwitz, & Durant, 2001; McLaney, DelBoca, & Babor, 1994).

Knight and colleagues (2001) present evidence regarding the internal consistency and test-retest reliability of the POSIT in a consecutive sample of 193 adolescents aged 15 to 18 years drawn from a general adolescent medical practice. These authors report that the 1-week test-retest reliability of all 10 subscales ranges from r = .72 to .88. Knight and colleagues reported α (internal consistency reliability) coefficients of .58 to .87 for seven subscales (Substance Use/Abuse, Mental Health Status, Family Relations, Peer Relations, Social Skills, Educational Status, and Aggressive Behavior/Delinquency). In clinical samples, the POSIT sub-scale internal consistency reliability ranges from .46 to .93. Dembo et al. (1996) reported that the 13- to 33-week κ values for subscales ranged from −.01 to .56 and concordance rates ranged from 69.5% to 98.6% for 563 adolescents entering a juvenile justice system.

The discriminant validity of the POSIT to identify adolescent mothers who were or were not drug abusers was confirmed by Scafidi, Field, Prodromidis, and Rahdert (1997). Fifty-five disadvantaged drug abusing adolescent mothers had significantly higher mean scores on the total score and all of the subscales than did 49 similar but non–drug abusing adolescent mothers. Experience with the POSIT across diverse groups of adolescents suggests that it is probably relevant for different cultural groups (Dembo, Schmeidler, Sue, Borden, & Manning, 1998; Scafidi et al.).

Demographic data were collected, including age, race, grade in school (five items) and whether the use of drugs or alcohol by “someone close to you” has “affected your life” (one item) using descriptive statistics. Twelve items from the Youth Risk Behavior Survey that measure self-reported use of various substances (lifetime, past year, past month) also were included in the questionnaire. After the last group session, the leaders met with their groups to solicit feedback from the teens regarding the usefulness and cultural relevance of the interventions. Group leaders’ feedback also was solicited.

RESULTS

Descriptive statistics revealed no significant differences between groups on demographic variables. All were 12 to 15 years of age at the beginning and in grade 7, 9, or 10. Most participants reported no personal experience with substance use, and about half indicated that they were concerned about substance abuse in someone “close to” them. Eleven participants described their race as black, and 5 reported being Hispanic. Attendance at the weekly meetings was very good and did not vary between the four groups.

The Table shows the pretest and posttest scores by group for all of the POSIT subscales. Higher values signify a larger number of problems in the particular domain. One-way analysis of variance was used to test for statistical significance. The small sample size resulted in insufficient power to detect statistically significant differences. The only difference approaching significance is in family relationships. At the trend level, the Teen Club participants reported fewer problems with family relationships immediately following the intervention, while the PALS group reported slightly more problems. Changes in self-reported substance use between time one and time two were not significant in the total sample or between groups.

Table.

Analysis of variance for between-group differences in mean scores on POSIT subscales between pre-intervention (Pre) and immediately following program completion (Post)

Subscale	Teen Club + PALS Mean (SD)		Teen Club Mean (SD)		p value	Between groups df	F All are NS
	Pre	Post	Pre	Post
A. Substance Use	0.14 (0.4)	0.86 (1.9)	0.22 (0.7)	0.63 (1.4)	0.66	1	1.699
B. Physical Health	2.86 (1.8)	2.00 (1.4)	1.78 (2.3)	1.50 (2.1)	0.30	1	.545
C. Mental Health	8.14 (6.9)	7.29 (5.1)	7.00 (6.2)	6.25 (4.6)	0.94	1	.697
D. Family Relationships	1.71 (1.1)	2.29 (1.3)	2.44 (2.6)	1.38 (1.2)	0.09	1	.589
E. Peer Relationships	3.86 (2.2)	3.29 (1.9)	2.33 (2.7)	2.63 (2.1)	0.30	1	.936
F. Educational Status	9.29 (6.2)	7.57 (4.7)	7.38 (4.6)	6.88 (4.3)	0.45	1	.551
G. Vocational Status	3.29 (1.3)	3.00 (2.2)	3.00 (1.5)	2.63 (1.1)	0.90	1	.545
H. Social Skills	3.43 (1.1)	4.00 (2.7)	2.88 (1.9)	2.75 (0.9)	0.52	1	.814
I. Leisure/Recreation	4.00 (1.4)	4.14 (0.7)	3.78 (1.4)	3.25 (1.7)	0.35	1	.671
J. Aggression/Delinquency	5.29 (4.0)	6.86 (3.1)	5.13 (4.0)	6.25 (4.1)	0.80	1	.334

The teens who had participated in the PALS intervention were: (a) more articulate about group purpose, (b) gave specific examples of learning, (c) recalled sessions on drugs, alcohol, assertiveness, and role playing, and (d) used skills from group in everyday situations and cited positive responses from peers, family, and teachers.

Group interviews were conducted by the group leaders at the end of the intervention phase. These interviews were tape recorded and addressed the following questions: (a) What was the purpose of the group? (b) What do you remember most? (c) How has group made a difference in your life? (d) What would you change about group? (e) What topics helped you at home, school, and in the community? and (f) How can we make the group most helpful for kids from your background? Many comments were difficult to hear on the tapes, and generally the PALS leaders pressed the teens harder for comments than did the Teen Club leaders. This situation might account for the more articulate responses from the PALS boys and girls. The tapes were reviewed by the researchers and a content analysis was performed to identify key responses and themes for each question. Selected comments are listed in Box 2.

BOX 2.

Selected group interview comments after 30-week intervention

Question	Boys		Girls
	PALS	Teen Club	PALS	Teen Club
What was the purpose of group?	“Prepare us for our teenage stage…so we can prevent risky behaviors….” “Give us tips for problems that might happen like when we are at home and your mom criticizes you”	“Keep out of [the] streets”	“We needed to get along together…learn more about life”	“…things to do after school”
What do you remember most?	“Role playing because we got to act ourselves and how to handle situations”	No comments	“Role playing” “I mostly remember when we tried to get [one girl in the group] to be assertive…express your feelings…when no one went behind our backs and told their friends…kept stuff in the group”	“The activities..” “Like the different subjects, like drugs, alcohol, school”
How has group made a difference in your life?	“Taught me to not have sex at a young age and I shouldn’t impregnate people, or do drugs…” “Taught me how to…deal with criticism”	No comments	“I don’t get aggressive towards my sisters and now I am assertive and my mom likes that more…my sister sometimes gets me really mad….”	“Because it makes me stay out of trouble after school” ”Be committed to something, helped me with my attitude”
What would you change about group?	“Really wouldn’t change anything…it is fun, teaches a lot” “I wouldn’t change anything, it was a fun experience, I know how to go on the street…it is a good program”	“Instead of cold sandwiches get hot” “Have more than one day [each week]” “Can’t think of anything to change” [have a] “co-ed group”	“…the food” “More days of PALS instead of just one day a week” “Less talk about drugs…every other question was about drugs”	“Nothing” “I like it…everything is cool” “Try to have people be committed to it not just come”
What topics helped you at home, school, and community?	“The drugs one because there was this kid who tried to offer us drugs…I told them what would happen if they did drugs” “Drugs…how to say no to drugs and high-risk behaviors…say no in an assertive way without getting shot…or people getting mad”	“Not picking on people”	“Dealing with parents assertively….” “I did what we practiced and it worked out fine [but] it hasn’t helped me at school but I wish it did”	“The one about sex and drugs” “…one about goals and personalities and tempers”
How can we make the group most helpful for kids from your background?	“Make PALS earlier [at younger ages]” “Drug abuse one is the main one for my background because a lot of Hispanics use drugs so we should talk about that”	No comments	“Have more activities like one day we work hard and one day we play…umm, we could play games, describing the topics like marijuana” “If they get Miss Tam and Miss Henderson [two of the group leaders] they’ll have a wonderful time”	“You can talk to Black kids the same way you talk to White kids” “I don’t think you can make it any more helpful…just keep it the way it is and get more kids to come”
What other topics would you like to discuss?	“Other things that people get addicted to…like TV, radio, video games….” “Like how to not drive drunk, clothing and hygiene cause some kids to stink”	“Education for college”	“Maybe if somebody comes on to you, how to get way…” “…walk away assertively”	“I think all the topics were good…but when people come here they should be more truthful”
How can you use the activities in your daily life?	“…hear negative feedback and use my skills to deal with criticism” “I’ll use that criticism thing a lot cause my mom likes to criticize me…those steps will help me a lot”	“…risks of AIDS…”	“I don’t know” “I’ll practice being assertive by not being aggressive”	“To try to accomplish my goals” “You really helped me”

DISCUSSION

Small group numbers limited the ability to detect quantitative differences in outcomes. However, some encouraging trends in the data were seen; physical and mental health improved slightly for all subjects, as did their educational and vocational status. Some of the POSIT subscale scores indicated slightly more problems after the intervention, although this was not statistically significant. For example, subscale scores for substance use and aggression/delinquency increased slightly between pretests and posttests in both conditions. These changes appear to be consistent with national norms for substance use and externalizing behaviors as teens get older.

The taped interviews revealed that the teens who had participated in the PALS intervention were: (a) more articulate about group purpose, (b) gave specific examples of learning, (c) recalled sessions on drugs, alcohol, assertiveness, and role playing, and (d) used skills from group in everyday situations and cited positive responses from peers, family, and teachers. It appeared that the teens in the PALS groups learned more concrete skills and were able to articulate the benefits of the group more than did those in only Teen Club. These findings might be related to group size, particular needs of the participants, and their maturity or lack of it. During the group interviews, the girls in both groups seemed more interested in showing off and acting out than in learning. The boys in both groups were more articulate than the girls in responding to the group interview questions. It was particularly interesting that the Teen Club girls “wanted more commitment” from the group members, suggesting that selection criteria for the group intervention should be reconsidered to ensure that teens are all appropriate for a group versus individual interventions.

According to feedback from the teens, the PALS intervention appears useful and culturally relevant for poor, inner-city, minority teens. Cost-benefit analysis of the quantitative findings does not support the expense of a 30-week intervention period. It is possible that a shorter duration of intervention would retain some of the benefits while utilizing scarce resources more cost effectively.

A larger sample is needed for sufficient statistical power to detect pretest and posttest differences. Because the group leaders expressed some difficulty controlling the group dynamics with 5 teens, increasing the size of each group may not be feasible. A larger grant that allows for multiple sites would increase the size of the sample and allow for a broader cross-section of teens to enhance reliability of results.

LIMITATIONS

The primary limitation was the small sample size. In addition, the closing of the teen clinic where the study was originally intended to occur (where the original Teen Club was operationalized) mandated a change in study setting that created considerable problems in recruiting the desired number and type of participants. The school setting greatly altered the Teen Club format being replicated in this study; there was no connection to primary care where the patients could receive needed health care and no home visitation by the CHN leader. The school setting also created the need for an additional institutional review board approval and limited the questioning of students about substance abuse in the family. The space allocated for the group interventions was located off the main corridor of the school, which was a noisy area with transient access to the room by nonparticipants.

FUTURE RESEARCH DIRECTIONS

Long-term follow-up data will be collected 6 and 12 months after completion of the intervention. A future multisite study in several settings would increase sample size and enhance generalizability of the results while allowing the small-group format to continue. It also would be desirable to reconnect the group interventions to an adolescent primary care practice. This situation would facilitate the recruitment of the targeted high-risk teens and allow for the full testing of the original model. It also is apparent from the group observations of the investigators and group leaders that more structure is needed to keep the teens on task. Empowering group leaders to use formal titles rather than first names, similar to the relationship of teachers to students or patients to providers, would reinforce the adult status of the leaders. Finally, the 30-week intervention is expensive and difficult to operationalize with part-time group leaders. It would be useful to test a shorter version of the intervention and have leaders who are part of the clinical staff designated to lead the groups. This plan would facilitate the recruitment and training of group leaders, provide the needed connection to the primary care practice, and facilitate full employment for the group leaders. In the current study, leaders were recruited for a few hours of work per week, which created challenges to keeping them employed over the entire 2- year period of intervention and follow-up.

CONCLUSIONS

Despite the small sample and logistical problems encountered, several trends in the data and participants’ comments suggest that the PALS plus Teen Club intervention has promise. These teens are using the cognitive-behavioral skills in their everyday life and finding them to be relevant and positively received by peers, teachers, and parents.

The boys’ reaction to both of the interventions was interesting. They tended to be more focused on the program than were the girls in either group. Obviously, this finding is a bit counter to the usual belief that teen girls are more mature than their male counterparts. Further refinement and testing of the intervention with a larger and more diverse sample is needed before any changes in clinical practice can be made.