Children in low-income, urban settings: Interventions to promote mental health and well-being

Children in Low-Income, Urban Settings Interventions to Promote Mental Health and Well-Being

Maureen M. Black and Ambika Krishnakumar University of Maryland School of Medicine

Urbanization provides unique political cultural economic, and educational opportunities for children and families. However, it may also have a negative impact on the mental health and well-being of children and adolescents, particularly when they are exposed to settings with high rates of crime, violence, delinquency, substance use, abuse, and poverty. Psychologists are well suited to intervene in problems associated with urbanization. However, most psychological services have been directed toward children who are experiencing problems, and there has been less focus on population-based or preemp- tive interventions that prevent problems before they occur This review presents 11 recommendations for urban interventions that build on individual family, and community strengths to promote the mental health and well- being of urban children and adolescents.

U r b a n areas have long been centers of political, cultural, economic, educational, and recreational importance. They offer opportunities for children

and families to obtain services or to come together and share similar interests. Yet, many families living in urban areas are confronted with the constant challenge of population density and associated problems, including housing that is either inadequate or unaffordable, crowding, limited access to resources, and high rates of crime. These conditions produce environments that interfere with children's development and increase their risk for adverse mental health problems. In industrialized countries, such as the United States and Canada, approximately three quarters of the population live in urban centers (Marsella, 1991). In developing countries, the number of cities is increasing at such a rapid rate that by the year 2000, there will be twice as many cities in developing countries as in industrialized countries (United Nations Children's Fund, 1996).

Urban life is complicated by the close proximity of families with differing levels of income: Upper income families who have the resources to enjoy the benefits and to avoid the negative aspects of cities and lower income families who have few economic resources and are often the victims of urbanization are juxtaposed. Many cities have witnessed the migration of middle income families to the suburbs. Although suburbanites continue to have access to the opportunities available in cities, they do

not have to endure the constant challenges of urban life. This pattern pulls support away from urban institutions, accentuates the disparity between families with high and low incomes, and often increases the frustration of families with few economic opportunities. For example, with middle income children in suburban schools and upper income children in private schools, urban public school systems are often left to children from low-income or poverty-stricken families (Parry-Jones, 1991). Because middle and upper income families are able to protect themselves and their children from many of the challenges of urbanization, much of the research on urbanization has focused on low-income families. The purpose of this article is to examine how urbanization influences the mental health and well-being of children in low-income settings and to propose recommendations for interventions that build on existing strengths.

Risks in the Lives of Low-Income, Urban Children Cities that lack the infrastructure to provide the protection and services that children and families require are jeopardizing the well-being of children. When living and working conditions become too confined, they breed stress, including decreased support for prosocial behavior, disintegration of extended families, and higher toler- ance for deviance. According to a recent report from The Annie E. Casey Foundation (1997), the percentage of children living in poor neighborhoods where there are large numbers of welfare recipients, unemployed individuals, and single-parent families increased from 3% in 1970 to 17% in 1990. The child poverty rate in America 's cities in 1989 was higher (twice as high) than that in the

Maureen M. Black and Ambika Krishnakumar, Department of Pediat- rics, University of Maryland School of Medicine.

Parts of this article were presented at the 104th Annual Convention of the American Psychological Association, Toronto, Ontario, Canada, August 1996.

Support for this article was partially provided by Grants MCJ- 240568 and MCJ-240621 from the Maternal and Child Health Research Program (Title V, Social Security Act), Health Resources and Services Administration, U.S. Department of Health and Human Services.

Correspondence concerning this article should be addressed to Maureen M. Black, Department of Pediatrics, Division of General Pedi- atrics, University of Maryland School of Medicine, 700 West Lombard Street, Baltimore, MD 21201. Electronic mail may be sent to mblack@ umaryland.edu.

June 1998 • American Psychologist Copyright 1998 by the American Psychological Association, Inc. 0003-066X/98/$2.00 Vol. 53, No. 6, 635-646

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suburbs, rising from 18% in 1969 to 27% in 1989. More children born in the inner cities of the United States were underweight at birth (9% compared with 7% nationwide), lived in homes where their parents were on public assistance (15% compared with 12% nationally), and dropped out of high school (14% compared with 11% nationwide). These structural conditions, in turn, increased the risk for mental health problems, including depression, substance use, delinquency, violence, maltreatment, and posttraumatic stress disorder (Harpham, 1994; Rutter, 1981).

Epidemiological studies from both industrialized and developing countries suggest that in comparison with children in rural areas, urban children, particularly those from low-income families, have elevated rates of delinquency (Barone, Weissberg, Kasprow, & Voyce, 1995; Rutter & Giller, 1983), aggression (Attar, Guerra, & To- lan, 1994; Guerra, Huesmann, Tolan, & Van-Acker, 1995; Huesmann & Guerra, 1997), violence (DuRant, Getts, Cadenhead, & Woods, 1995), psychological disturbances (Richman, Stevenson, & Graham, 1982; Rutter, Cox, Tu- pling, Berger, & Yule, 1975), behavior problems (Rutter, 1981), child abuse and neglect (Coulton, Korbin, Su, & Chow, 1995; Drake & Pandey, 1996; Zayas, 1995), and lower educational and occupational expectations (Cook et al., 1996). Yet, it is not clear how urbanization per se influences children and increases the likelihood of behav, ior problems and mental illness. Although some may ar- gue that cities attract individuals with behavior problems and mental illness and that there is closer scrutiny of mental health problems in urban settings, Rutter (1981) showed that these potential biases did not explain his findings as to why children from low-income families in inner London experienced more stress than those on the Isle of Wight. He suggested that the multiple stresses of urban life increased children's susceptibility to behavior problems and mental illness and were often manifested as chronic disorders with an early onset. Although families can often protect their children from urban stress, when families are not functioning well and lack a sense of control themselves, they may be unable to protect their children. Thus, interventions are needed to promote strategies of resilience to overcome the challenges of urban life for children, their families, and communities.

Resilience of Children and Families Resilience is an important concept because it identifies how children, families, and communities are able to cope and to thrive despite environmental challenges, such as the stresses common in urban settings (McLoyd, 1990, 1998; National Research Council, Commission on Be- havioral and Social Sciences and Education, 1993; Slaughter, 1988). Although resilience is often conceptual- ized as an individual construct based on factors such as personality and intelligence (Garmezy, Masten, & Tel- legen, 1984; Masten & Coatsworth, 1998; Masten et al., 1988), there are functional qualities of family life that contribute to resilience and success (Spencer, 1990;

Stack, 1974). For example, in African American families, strong kinship bonds, the elasticity and adaptability of households and family roles, high achievement orientation, the central role of spirituality and religion, racial biculturalism, positive self-esteem, and development of ethnic awareness often buffer youth against the negative effects of urban violence (Hill, 1971; Littlejohn Blake & Darling, 1993).

Families may try to protect their children from the negative influences of communities by providing struc- tured activities, such as music, sports, or recreational centers. However, communities and families with few economic resources are often left without safe options for their children. Families may then try to protect their children by restricting them from community activities, such as playing outside (Lorion & Saltzman, 1993), or by teaching them to avoid dangerous areas (or at least to move out of range at the sound of gunfire or sirens; Kotlowitz, 1991). Although restricting outside activities may protect children from street violence, restrictive strategies may imperil children's development by limiting their opportunities to establish independence and autonomy. Children who remain inside often spend many hours in the passive, sedentary activity of watching television and may be exposed to violent role models and violent methods for resolving conflicts (Centerwall, 1992). In addition, restrictive strategies undermine the sense of community and make children (and adults) feel as though they are prisoners in their own homes. Yet, for families living in the midst of high rates of urban violence, restrictive strategies may reflect a realistic appraisal of the threats, risks, and temptations confronting children (Baumrind, 1991; Garbarino, 1995). Thus, parents of children in urban communities with high rates of crime may have to look for creative opportunities for their children to obtain age-appropriate activities because the potential to become either a victim or a perpetrator of urban violence is so high.

When the resilience strategies of children and families are inadequate and mental health problems dominate, psychologists are often called on to provide services. Although many psychologists and other social scientists incorporate family interactions into their conceptualiza- tions of children's behavior and development, context is often overlooked (Garbarino, 1995). Theoretical models are needed that incorporate the risks and adaptive strategies necessary for children and their families to thrive in urban environments.

Theoretical Models Structural Models

Urbanization is often regarded as a structural concept defined by rates of population density, together with in- dexes of industrialization and economic development. In this type of research, the unit of analysis is a census tract, a neighborhood, or a particular geographical area, and researchers attempt to link structural data to children's

636 June 1998 • American Psychologist

mental health and well-being, including rates of infant mortality, low birth weight, immunizations, child maltreatment, adolescent pregnancy, delinquency, and high school graduation. The poverty that often accompanies urbanization is associated with negative physical and mental health outcomes for children (McLoyd, 1990, 1998). Not only are children in low-income, urban communities exposed to illnesses associated with crowding and unsanitary conditions, but they may have limited access to appropriate developmental challenges and stim- ulation (National Commission on Children, 1991). How- ever, without information on the mechanisms linking urbanization to children's health and well-being, professionals and policymakers are left with little information to guide interventions to prevent the negative effects of urbanization on children.

B ursik and Grasmick (1993) emphasized that physical or structural components comprise only one aspect of a community. To understand how a community func- tions, it is necessary to examine the social networks, the sense of identity, and the continuity within the community. In a similar vein, Coleman (1988) argued that interventions for children should include the linkages or relationships between children and the larger society. In other words, models that examine the interconnections and relationships among community residents and institutions are necessary to understand how children are influenced by urban settings.

Ecological Models Ecological models may be helpful in examining how urbanization impacts children because they highlight how children are influenced by multiple interacting systems, including caregivers and the social context in which they live (Bronfenbrenner, 1979). Because ecological models are based on systems theory, feedback and reciprocity are central concepts, and children are regarded as active participants who contribute to interactions within their environment rather than merely as passive recipients. Much of the research on children's mental health and well-being has focused either on children or on their proximal environments--the family and the correspond- ing daily activities, roles, expectations, and interpersonal relationships within the family. However, children's mental health and well-being are also influenced by their interactions with other caregivers or in other settings (e.g., neighborhoods, day care, schools, churches). Interactions across settings are important because they provide a col- lective socialization experience whereby children learn to cope with differing sets of activities, roles, expectations, and relationships (Jencks & Mayer, 1990). At broader levels, children may be influenced by systems that impact them indirectly, rather than directly, including their family's financial, emotional, or physical status. For example, Brooks-Gunn, Duncan, Klebanov, and Sealand (1993) demonstrated that children from affluent neighborhoods had higher cognitive scores and fewer teenage births and were less likely to drop out of school than

were children from low-income neighborhoods, even when differences in the socioeconomic characteristics of the families were controlled statistically. Children raised in affluent communities may be exposed to more prosocial role models and better services. In contrast, the racial segregation, crime, limited resources, and violence common to many low-income, urban communities may hinder the ability of families to protect themselves and their children (McLoyd, 1998). Finally, children are also influenced by cultural or political beliefs and structures, frequently operationalized through their families (Har- rison, Wilson, Pine, Chan,& Buriel, 1990).

Families serve as a critical link between children and other aspects of their environment. In a study of urban children living in a high-crime area, Richters and Martinez (1993) found that the quality of parent-child interactions mediated the relationship between neighborhood violence and children's externalizing behavior. Children who experienced violence but had parents who were concerned and involved in their school activities had lower rates of aggression and other externalizing behaviors. Likewise, influences from the larger society (e.g., community poverty) impact children directly through lack of resources, such as safe playgrounds, recreational centers, and role models, and indirectly through increased stress on their families.

Solutions to the issues confronting urban children and families are neither simple nor straightforward. Mul- tifactorial strategies that provide recommendations at the levels of policies, communities, families, and children are needed to secure the health and well-being of children who will become future urban leaders.

Interventions to Promote the Well-Being of Urban Children

There is widespread recognition of the role that psychologists can play in interventions that alter behavior (Lip- sey & Wilson, 1993). Developing interventions and programs for children and families is a central component of the training and practice of psychology. With expertise and training in research and evaluation methodology, psychopathology, family systems theory, theories of behavioral change, intervention strategies, and interdisciplinary collaboration, psychologists are well versed in developing individual and family-level interventions. This expertise should be extended to community-level interventions that promote strategies of resilience for children and families as a community. Changes in health and social policies at the federal level require that psychologists redefine their role within new health care and social service systems. As policymakers recognize that promoting the well-being of urban children is a responsible fiscal policy, they will look for guidelines to inform them on social policy recommendations. See Table 1 for examples of interventions that are based on ecological theory and are designed to promote the mental health and well-being of urban children and families.

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Table ! Examples of Urban Programs for Families and Children

Urban program Level of intervention Target Purpose

Community development Eastside Community Investments, Inc.,

Indianapolis, IN (Kingsley et al., 1997 I

Kenilworth-Parkside Public Housing Development Project, Washington, DC (Kingsley et al., 1997)

Boyd-Booth Community Program, Baltimore, MD (Kingsley et al., 19971

Children's well-being Safe Kids/Healthy Neighborhoods

Injury Prevention Program, Harlem, NY (Davidson et al., 1994)

High/Scope Perry Preschool Program {Schweinhart & Weikart, 1988)

Violence Prevention Project, Boston, MA (Hausman et al., 1995)

Positive Adolescent Choices Training (Hammond, 1991)

Focus on Kids (Galbraith et al., 1996; Stanton et al., 1996)

Project ALERT (Bell et al., 1993) Infant Health and Development

Program (Infant Health and Development Program, 1990)

Promoting Alternative Thinking Strategies Curriculum (Greenberg et al., 1995)

Child Development Community Policing Program (Marans, 1995)

Home-based service Low-income pregnant women

(Kitzman et al., 1997; Olds et al., 19971

Children with failure-to-thrive {Black et al., 1995)

Children of drug-abusing mothers (Black et al., 1994)

Multisystematic model of treatment (Henggler & Borduin, 1990)

Nutritional program Special Supplementation Program for

Women, Infants, and Children (Chelimsky, 1984)

Universal-selective Community



Universal-selective Children



Selective-indicated Children

Selective Children

Universal-selective Children Selective Children

Universal-indicated Children

Selective-indicated Children

Selective

Indicated

Indicated

Indicated

Selective

Mothers and families

Children and families

Children and mothers

Children and families

Mothers

Enhance job skills and promote housing development

Revitalize housing projects and promote the well-being of residents

Eradicate drugs from a southwest Baltimore community

Reduce injuries among children by promoting the use of safe playground equipment

Promote young children's skills in dealing with violence in their schools and communities

Prevent youth violence through media and direct communication

Manage violence and anger in volatile situations

Reduce risk of HIV among low-income African American adolescents

Prevent drug use Promote health and development in

children with low birth weight

Promote emotional competence in children in regular and special needs classroom

Directed toward youth involved in violence either as victims or as perpetrators

Prevent low birth weight deliveries, promote parenting, prevent child abuse and neglect

Promote growth and development among children with failure-to-thrive

Promote parenting skills among drug- abusing mothers

Prevent violence among juvenile offenders

Directed at low-income pregnant and postpartum mothers

By incorporating a social and ecological approach with a traditional focus on individual functioning, psychologists can help children and families build strategies of resilience against the challenges of urban life (Coie et al., 1993). In addition to providing services to urban children and families who are experiencing mental health problems, psychologists can integrate their knowledge of

families and children with the expertise of other social scientists and urban planners to promote community development and attitudes of self-reliance, self-conviction, and obligation among families in urban neighborhoods. The following recommendations serve as guidelines for psychologists working with children and families in urban settings.


Consider the Social Context When Evaluating Children's Needs and Developing Interventions

Children's development is the product of their interactions with their families, neighborhoods, culture, physical environments, society, and the period of history within which they live (Lerner, 1995; Sampson, 1997). Systems that surround children are constantly changing and evolv- ing (Ford & Lerner, 1992). At their optimal level, they provide opportunities and support for developing children. However, in the case of low-income, urban children, the surrounding systems are usually low in resources and present a great deal of risk (Garbarino, 1995). Successful interventions and programs for children will improve their opportunities for resilience, often by improving the environments in which they live. For example, the Vio- lence Prevention Project in Boston is a community-based effort to prevent youth violence. It is a comprehensive program that is theoretically based and uses media and direct communication. Process evaluations have demonstrated that the intervention is penetrating the community (Hausman, Spivak, & Prothrow-Stith, 1995). Interven- tions that incorporate the values, culture, and norms of the community in their efforts to enhance children's well- being are most likely to be successful because newly learned behavior is easier to implement in a culturally familiar and supportive environment. For example, because extended families are often important in the lives of many African American children (Spencer, 1990; Stack, 1974), they should be an integral part of intervention programs for African American children and families.

Insights into the contextual validity of programs for children and youth in low-income neighborhoods can be obtained from qualitative methods, such as in-depth interviews and participatory observations. Qualitative analyses of children's lives in books such as The Corner: A Year in the Life of an Inner-City Neighborhood (Si- mon & Burns, 1997) follow the lives of children in urban neighborhoods and provide a picture of the community organization, parental strategies, and children's lives as they negotiate their survival. These ethnographic ac- counts place the lives of urban children in their ecological context and provide vital information for psychologists as they develop programs.

Build Programs With Community Initiatives and Participation

In keeping with ecological models, programs for children need to consider their ecological context. By collaborat- ing with families and communities, psychologists are working to ensure cultural relevance and sustainability of programs. Engaging the local community in the design, implementation, and evaluation of programs for children and families empowers the community and enhances the efficacy of the program. By incorporating the opinions, value systems, culture, and experiences of community members into program development and implementation, community members become central participants in the

enforcement of the program. An example of this type of approach can be found in an evaluation model (Develop- ment-in-Context Evaluation [DICE]) proposed by Weiss and Greene (1992) and described by a group of psychologists concerned about programs for urban youth (Ostrom, Lerner, & Freel, 1995). In the proposed framework, the identification of the community issues begins with community members who are involved in the planning, exe- cution, and evaluation of the program.

The DICE model could have particular relevance for psychologists who are developing interventions for low-income, urban children because it links together youth, their families, and the community to address issues that are relevant to their lives. Kingsley, McNeely, and Gibson (1997) gave several examples of such community-initiated efforts. One example was a resident-owned corporation in Indianapolis, Indiana, that trained local residents in housing repairs, thereby preparing residents for participation in the job market. Another example involved the formation of a tenants' association in a Wash- ington, DC, public-housing project that took over its management and set up its own agenda for social service, educational, and economic development. The formation of the tenants' association improved rent collections by 77% in the first year. Although these examples are not targeted toward children, they have indirect benefits to children through opportunities for families. The success of these programs illustrates that the sustainability of programs or interventions is enhanced when they involve program recipients and are integrated into existing service systems.

Integrated programs for urban youth often require interdisciplinary collaboration among community residents, schools, churches, businesses, police officers, and politicians. The Child Development Community Policing Program is an example of an integrated collaboration that includes the community, the police department, and mental health providers. It is directed toward youth who have been involved with violence as victims or perpetrators (Marans, 1995). The program quickly mobilizes treatment, ensures that providers know the real challenges facing youth, helps the police focus on prevention, and evaluates program services. Another example of an integrated program designed to reduce violence and to make urban streets safer for children is a community-sponsored effort on drug eradication in Baltimore with the help of the police and other agencies. Between 1994 and 1995, the community experienced a 52% decrease in violence and an 80% drop in arrests for drugs (Kingsley et al., 1997). Finally, Durlak and Wells (1997) discussed the effectiveness of programs that extended beyond individual youth to modify the school environment in a recent meta-analysis of 177 primary prevention programs designed to prevent behavioral and social problems during childhood. Such success stories are encouraging for urban children and spur the need for more community- based and initiated efforts.


Psychologists can add a unique perspective to community-based models to promote the well-being of urban children because they can help build interfamily and community trust and collaboration. For example, Webster (1997) suggested that parent training programs should be offered in communities where they can play a role in bringing families together to improve parenting practices and enhance positive behavior. As a result, parents learn to depend on other parents for positive support. In addition, by involving themselves in their children's schools and community, parents build community strength and cohesiveness.

Psychologists can play the role of supporter and arbitrator, thereby facilitating program planning and strategies for enhancing resilience at the family and community levels. Playing the role of strategist, psychologists can help community members prioritize and identify major issues and short- and long-term goals to promote services for urban children. Tapping into the strengths of the community and the abilities of the residents builds empowerment, ownership, and pride and establishes an effective model for children to view their families and communities as responsible citizens (Fetterman, Kaft- arian, & Wandersman, 1996).

Examine Alternate Pathways and Linking Mechanisms in the Association Between Context and the Well-Being of Children

Children and adolescents in low-income, urban families are at risk for a variety of mental health and adjustment problems, including delinquency, substance abuse, teenage pregnancy, violence, and school failure (Dryfoos, 1990; Wilson, 1987). These behaviors do not usually occur in isolation; in fact, they often co-occur and have common risk factors (Jesso~; 1993; Lerner, 1995). In addition to risk factors at the community level, such as urban violence, children are exposed to individual and family-level risk factors. Individ- ual risk factors include hyperactivity, intellectual deficits (Luthat; 1991), and deficient coping skills (Lerner, 1995). There are multiple family-level risk factors, including family violence (Straus & Gelles, 1986), a lack of nurturance and support, and inadequate parental supervision (Loeber & Stouthamer-Loeber, 1986). Although each risk factor can have a direct influence on children's mental health and well- being, risk factors accrue cumulatively to place children and adolescents at exponentially greater risk for youth mal- adjustment (Garmezy et al., 1984). Moreover, there are often indirect effects of community or environmental risk factors, operating through intervening variables, such as family management practices (Larzelere & Patterson, 1990).

Programs designed to promote strategies for allevi- ating risks among children, families, and communities are complex and require hierarchical interventions developed in collaboration with communities, families, parents, and individual children (Fonseka & Malhotra, 1994; Marsella, 1991). Programs should incorporate an understanding of how and under what conditions urbanization impacts children and families.

Promote Interventions at Multiple Levels

Psychological services have traditionally been delivered in tertiary settings, based on referrals from primary care providers. At the tertiary level, children who have experienced dysfunction or distress are referred to a psychologist or other health care provider whose goal is to prevent further dysfunction. In contrast, in primary prevention, providers attempt to prevent dysfunction before it occurs by promoting strategies of resilience that protect children. During secondary prevention, providers focus their preventive efforts on children who are at high risk for developing a problem but have not yet been identified as experiencing it.

A report from the Institute of Medicine (Mrazek & Haggerty, 1994) includes a similar categorization that can be applied to the prevention of urban problems. Uni- versal or population-based interventions are designed to prevent urban problems and promote mental health among all urban children. They may include mass media campaigns, public service announcements, or universal policies such as drug-free school zones. For example, the Safe Kids/Healthy Neighborhoods Injury Prevention Program in Harlem, New York, demonstrated that safe playground equipment was associated with reductions in injuries for the entire community (Davidson et al., 1994). An important advantage of population-based interventions is that they are available to all, rather than possibly stigmatizing youth who are identified as high risk. Uni- versal interventions can be very effective, particularly when they carry social and legal sanctions.

Selective interventions are directed toward individuals or groups of individuals who are at increased risk of experiencing a negative outcome. For example, selective interventions have been designed to reduce the likelihood of violence among urban youth who are at increased risk for violent behavior. Unlike universal interventions, selective interventions are targeted to specific youth and are often individually tailored. For example, Positive Adoles- cent Choices Training is a culturally relevant intervention that focuses on violence education, anger management, and prosocial skills training to help youth learn to negotiate through potentially conflictual situations (Hammond, 1991). The program is centered around three instructional videotapes (Dealing With Anger: Givin' It, Takin' It, and Workin' It Out) that incorporate African American youth, street language, and familiar conflict situations. Hammond and Yung (1993) reported that participation in the intervention resulted in fewer referrals to juvenile court and less likelihood of violent offenses among youth with prior juvenile involvement. The Special Supplementation Program for Women, Infants, and Children (WlC) provides food supplements and health care to low-income pregnant and postpartum women with nutritional risks and is another example of selected intervention. Evaluations of this program indicate that infants' birth weights are higher and adverse birth outcomes are lower among mothers who participate in the WlC program (Chelimsky, 1984; Frisbie,


Biegler, de Turk, Forbes, & Pullum, 1997). Another advantage of selected interventions is that because programs target common risk factors among children and families, often at a community level, individual stigmata associated with joining the program are often reduced.

Indicated interventions are directed toward children and families who are experiencing negative consequences associated with urbanization. Psychology's primary focus has been directed toward indicated interventions, often with children identified as having a problem, and there are many examples of successful interventions. For example, the multisystematic model of treatment (MST) developed by Henggler and Borduin (1990) is an inten- sive, home-based strategy used to prevent violence among juvenile offenders. Based on ecological theory, with an emphasis on family organization and communication patterns, MST views families as partners and as active team members. Randomized clinical trials with juvenile offenders have shown that youth in the MST condition had less criminal activity and were less likely to be rearrested or incarcerated more than two years after the intervention (Henggler, Melton, & Smith, 1992; Henggler, Melton, Smith, Schoenwald, & Hanley, 1993).

Psychologists have demonstrated their skills in building strategies for resilience that promote mental health and well-being of children and families. By broad- ening their focus from indicated to selected and universal levels of intervention, psychologists can extend their impact to social networks and urban communities.

Consider Developmental Changes Among Children in Urban Settings

As children grow and develop, they become more inde- pendent and autonomous, and their skills and needs change (Ford & Lerner, 1992). Although children of all ages require nurturance, protection, and opportunities for development, the strategies used to protect children vary depending on their developmental level. For example, restrictive strategies that parents may use to limit children's exposure to dangerous situations may be effective when children are young. However, adolescents are often less responsive to restrictive policies established by their parents because they are guided by a goal to establish independence and autonomy. Not only are adolescents often attracted to danger and risky behavior, but they may have difficulty judging their own vulnerability and see themselves as invincible. Thus, interventions to promote mental health and well-being among urban adolescents have to account for their need for independence and autonomy while ensuring their safety. Focus on Kids is one such program developed to reduce the risk for HIV infection among low-income African American adolescents in urban housing projects (Galbraith et al., 1996; Stanton et al., 1996). The program was a collaborative effort among adolescents, community agencies, and university professionals to promote safer sexual practices. The program was effective in increasing adolescents' rate of condom use and their intention to use condoms.

Address Issues of Resilience in Individuals, Families, and Communities as Protective Factors That Determine Youth Behavior Jarrett (1995) presented five strategies associated with resilience among urban children and families living in socially toxic environments. These strategies highlight the importance of ecological models because they include recommendations at the individual, family, and community levels. The first strategy includes supportive adults, both within the family and within the community. Adults provide guidance, feedback, and protection to children as they oversee their activities and serve as role models. This strategy could be accomplished through community service programs that show adults how to be supportive to children and adolescents and that provide opportunities for children and adolescents to meet adults and to interact with them through community activities. The second strategy is to limit interaction between the family and the toxic components of the community. Although at first glance this recommendation may appear to undermine community cohesion and to promote isolation, it is meant to protect children from negative influences, such as drug dealers, and to reinforce the values of the family. The third strategy includes rigorous monitoring, whereby parents know where their children are, what they are doing, and whom they are with. Monitoring limits the opportunities children have to engage in maladaptive or dangerous behavior and lets children know that their parents care about them and want to know what they are doing (Lam- born, Mounts, Steinberg, & Dornbusch, 1991; Patterson, 1982). Adolescents who are monitored are less likely to engage in risky behavior and more likely to perform well in school (Steinberg, Lamborn, Dornbusch, & Darling, 1992). The fourth strategy is to facilitate interactions with institutions and organizations that promote growth. Schools are the primary socializing agent for children in most communities, and many schools reach out to communities by facilitating community programs (Ramu- aldi & Sandoval, 1995; Simoni & Adelman, 1993). Work- ing with schools and other community agencies (e.g., churches) can be an effective strategy in building positive opportunities for children and adolescents. The final strategy is the development of individual skills and competen- cies that enable children and adolescents to avoid the pressures of urban life. For example, drug dealers frequently try to lure adolescents into the drug trade through quick money. With few economic resources from their families, it is often difficult for youth to resist this tempta- tion. Although the most effective strategy is to avoid encounters with drug dealers, negotiation skills may help urban youth refuse the advances of drug dealers.

Prepare for Policy Recommendations by Incorporating Accountability and Cost inta Intervention Programs Interventions to promote resilience among urban children and adolescents can be classified into three categories on the basis of their purpose and design: efficacy, effective-


ness, and efficiency (Feinstein, 1977). These categories are critical in the link between research and policy. Effi- cacy studies are the first stage, and they are conducted to determine if the intervention works under optimal or ideal conditions. Demonstration projects that include funds for implementation and evaluation or university- based intervention trials with highlytrained personnel, such as the Infant Health and Development Program (1990), are examples of efficacy studies. Efficacy trials are highly informative, but they do not examine whether the intervention can be applied in naturalistic settings without external controls. In contrast, effectiveness trials assess whether an intervention works in the field and can be integrated into existing systems. For example, Project ALERT is a school-based intervention to prevent drug use that has been implemented and evaluated in the Phila- delphia public school system (Bell, Ellickson, & Har- rison, 1993). Finally, efficiency refers to an analysis of the costs and benefits of the intervention. Investigators who conduct effectiveness trials in schools or other community settings and include an efficiency analysis can be convincing when they advocate the transition from research to policy because they can address the implementation and economic questions often posed by policymakers (Barnett, 1993). An excellent example of longi- tudinal intervention research that includes efficacy, effectiveness, and efficiency analyses is the High/Scope Perry Preschool Program (Schweinhart & Weikart, 1988). Data from early efficacy trials, together with comprehensive efficiency analyses conducted for over 20 years, served as a basis for the expansion of Head Start programs for low-income children.

Policymakers have a fiscal responsibility to their constituents. Therefore, advocacy for programs for children and adolescents is most likely to be successful when it includes information about the efficiency of the intervention.

Train .Young Professionals to Work in Urban Settings

Urban projects should include trainees to ensure that the next generation of psychologists is trained in the science of prevention, thereby sustaining the collaborations (Coie et al., 1993). By participating in urban projects, students extend their knowledge beyond the basic principles of intervention design and evaluation and learn to work with community members and professionals from other disci- plines in the prevention of urban problems.

Make Intervention Programs Accessible to Urban Children and Families

Over the past few years, psychologists have expanded their work from tertiary or indicated interventions delivered in clinics or offices to include secondary or selected interventions delivered in homes, schools, and communities. There has been enthusiastic support for school-based interventions partially because schools are an excellent venue for universal or selective interventions (Kolbe, Col-

lins, & Cortese, 1997; Short, 1997; Weinberg, 1989). For example, when the Promoting Alternative Thinking Strategies Curriculum, which was designed to promote emotional competence, was introduced into second- and third-grade classrooms for students in special needs and regular classes, both groups of students demonstrated improvements in vocabulary and fluency in discussing emotional experiences, beliefs regarding emotions, and developmental understanding of emotions (Greenberg, Kusche, Cook, & Quamma, 1995). These findings have implications for policy because they illustrate that students in both special needs and regular classes can benefit from the universal intervention.

School-based health centers are another example because they provide access to preventive health services while educating youth about activities to promote their well-being. Topics such as group counseling, life planning, and career orientation are often incorporated into school-based centers (Dryfoos, 1994; Kolbe et al., 1997) and illustrate how school-based centers have expanded beyond a medical definition of health. The movement to integrate school-linked services with families can increase the availability and accessibility of school programs for the wider community.

Home-based services to promote parenting and to prevent growth and developmental delays in children have attracted national attention. Most home-based programs are directed toward families who are at risk through their low-income status (Kitzman, Cole, Yoos, & Olds, 1997; Olds et al., 1997), maternal behavior (e.g., drug abuse; Black et al., 1994), or children's health status (e.g., growth deficiency; Black, Dubowitz, Hutcheson, Berenson-Howard, & Starr, 1995). The findings of these theoretically based, systematically conducted, home-visiting programs have been promising. Successful home- based programs require careful planning, supervision, and evaluation (Kitzman et al., 1997). A recent 15-year follow-up evaluation of a home-visiting program among low-income mothers demonstrated reductions in subse- quent pregnancies, use of welfare, child abuse and neglect, and maternal criminal behavior (Olds et al., 1997). These findings illustrate the important role that home- based services can play in promoting children's well- being.

Develop Interventions Based on Theoretical Frameworks and Methodological Rigor

In the past, many interventions were based on elimination or reduction of risk factors with little attention to theory. However, the link between risk factors and behavior is often indirect and influenced by social-psychological factors, such as family variables (Bronfenbrenner, 1993; Seifer & Sameroff, 1987). When interventions are based on theories of behavioral or developmental change, investigators are protected against missing critical variables and are better able to interpret their findings. Without knowing how and why interventions work (or don't work), urban planners and policymakers have difficulty


replicating successful interventions and avoiding the pit- falls of unsuccessful ones. For example, a recent survey among parents of urban youth and providers from a mental health clinic indicated that whereas parents were concerned about their children' s school performance, providers were concerned about depression (Pottick, Lerman, & Micchelli, 1992). Compliance and success are likely to be difficult if providers, families, and communities do not share similar views of the problems and plans for intervention. For this reason, programs should be built on consultation with adolescents and families such that views from all concerned can be incorporated.

Psychologists are trained to develop intervention strategies using rigorous scientific methods, whether the intervention is directed toward one child or adolescent in therapy or toward a population. These scientific methods yield data that can be used to evaluate the efficacy, effectiveness, or efficiency of an intervention (Fetterman et al., 1996). Much attention has been directed to the need for outcome studies that are focused on reducing public health problems, such as violence, and improving the lives of urban children. Evaluations of interventions that are limited to process measures (e.g., number of children served, number of sessions conducted) or changes in atti- tude are often insufficient. Policymakers are looking for credible evidence regarding the impact interventions have on the functional behavior of urban children and adolescents.

The randomized clinical trial has been recom- mended as the optimal design for evaluating an intervention (Meinert, 1986). However, in some urban settings, randomization may not be possible or desirable, particularly when an environmental or ecological component is under investigation. There are quasi-experimental proce- dures to reduce bias and ensure validity (Cook & Camp- bell, 1977). Regardless of the overall design, the intervention should be clearly defined and applied and the sample should be described clearly so others can make informed decisions about replication and generalizability. Method- ological problems such as small sample sizes, lack of group equivalence, evaluators who are aware of group assignment, lack of objective outcome measures, few process measures, and lack of follow-up can undermine the evaluation and cast doubt on the usefulness of the entire intervention (Black, 1991).

Combine Cultural and Developmental Sensitivity Into Intervention Programs Innovative, culturally and developmentally sensitive intervention strategies are often necessary to reach low-income, urban families who may question the usefulness of traditional educational methods and may not visit phy- sicians, psychologists, or other traditional health care providers (King, 1991). In extreme situations, families are replaced by "the street," and children are raised with few of the traditional structures used to define family life. There are millions of homeless or street children in Latin America, Asia, and Africa, many of whom have

health and behavioral problems. Their access to services is further limited by their nontraditional living situation, their lack of records or insurance, their distrust of traditional services, and the hesitancy of service providers to undertake complex cases, particularly when there may be small likelihood of receiving compensation.

Innovative strategies for urban youth include taking services to shopping malls or schools where they are more accessible. In addition, videotapes have been used effectively with urban parents to increase knowledge and problem-solving skills regarding AIDS prevention (Ka- lichman, Kelly, Hunter, Murphy, & Tyler, 1993; Winett et al., 1993) and with urban adolescent mothers to increase their knowledge and behavior regarding communication and parenting (Black & Teti, 1997). Their effectiveness may be explained by social learning theory, which relies on altering behavior through culturally consistent model- ing (Bandura, 1986) and may be a particularly effective strategy for urban children or families who do not want to leave their homes to attend group meetings.

Conclusion Although psychology has made important contributions to the solution of urban challenges by providing tertiary care to urban children and adolescents with mental health problems, the role of psychology can be broadened to include universal and selected interventions to prevent mental health problems and to promote the well-being of urban children and families. Psychologists are uniquely trained in prevention science and have made major contributions in areas such as the prevention of AIDS risk behaviors and violence. Now the challenge is to move beyond efficacy studies to examine the effectiveness and efficiency of interventions to promote healthy behavior among children and adolescents in real-world urban settings. Armed with this information, psychologists can work with social policymakers to promote sustainable services to prevent urban problems. Through collaboration with community organizations and other professionals in the planning, implementation, and evaluation of interventions directed toward children and families, psychologists can work to resolve many of the urban challenges and to promote the mental health and well-being of urban children.

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Documents

Children in low-income, urban settings: Interventions to promote mental health and well-being