When interventions harm: Peer groups and problem behavior

I read a peer reviewed research paper discussing the negative effects of peer group interventions, thinking it might be helpful for social work practice regarding high-risk youths.
 Dishion, T. J., McCord, J., & Poulin, F. (1999). When interventions harm: Peer groups and problem behavior. American psychologist, 54(9), 755.  

Below is my summary of this paper 

This article explored developmental and intervention evidence relevant to iatrogenic effects (contagion effects) in peer-group interventions.  

Contrary to historical assumptions about the beneficial effects of friendships on children's social development, adolescence is also a time when such relationships can undermine healthy development (see Hartup, 1996). We have spent the past five years studying the subtle but powerful influence of deviant friendships on escalations in problem behavior during adolescence. Much of this research was conducted using the Oregon Youth Study (OYS) boys (Capaldi & Patterson, 1987; Patterson, Reid, & Dishion, 1992).

1.     The factors relate to iatrogenic effects in treatment

1)     AGE

Additional analyses revealed that older (i.e., postpubertal) youth, with the highest initial level of problem behavior, were most susceptible to the iatrogenic effect (Poulin et al., in press).

Although the intervention groups were closely supervised to prevent direct encouragement of problem behavior, perusal of the videotapes suggests that the older children mobilized more group attention than their younger, less deviant counterparts. Attention in the group may have been elicited, not so much by the content of the discussions, as by dress, behavior, and nonverbal expressions. These ideas will be explored in future analyses

The data from both intervention studies suggest that the older, more deviant children were the most vulnerable to iatrogenic effects from peer aggregation. This fact is consistent with recent developmental research on the influence of friends.

2)     The level of delinquency

In early adolescence, youth with moderate levels of delinquency, and who had deviant friends, were those who escalated to more serious forms of antisocial behavior (Coie, Miller-Johnson, Terry, Maumary-Gremaud, & Lochman, 1996; Vitaro, Tremblay, Kerr, Pagani, & Bukowski, 1997). Poulin, Dishion, and Haas (1999) found that boys with the poorest relationships and highest delinquency were most vulnerable to deviancy training, with

respect to increasing delinquent behavior

2.     The mechanism of iatrogenic effects

We offer two possible processes that might explain the converging evidence from intervention and developmental research on the influence of peers on social development: (a) youth being actively reinforced through laughter, social attention, and interest for deviant behavior are likely to increase such behavior (Dishion et al., 1995; Dishion et al., 1997; Dishion, Spracklen, et al., 1996); and (b) high-risk adolescents derive meaning and values from the deviancy training process that provides the cognitive basis for motivation to commit delinquent acts in the future (i.e., construct theory; McCord, 1997, 1999)         .

Both processes suggest that repetition of contact within the peer-group intervention would create the iatrogenic effect observed in these two intervention studies, especially among those youth likely to engage in deviant talk and behavior primarily in the company of peers. We hypothesize that the reinforcement processes within the peer groups are quite subtle and potentially powerful. For example, Buehler, Patterson, and Furniss (1966) found that within institutional settings, peers provided a rate of reinforcement of 9-to-l, compared with adult staff, suggesting that the density of reinforcement from peers can be so high it seriously undermines adult guidance.

In our analysis of therapist and client behavior predicting the magnitude of the iatrogenic effect, we found that observer impressions of therapist effectiveness were positively associated with growth in subsequent problem behavior (Dishion, Poulin, Hunt, and Van Male, 1998).

3.     What can we do

Based on the studies reviewed, there is reason to be cautious and to avoid aggregating young high-risk adolescents into intervention groups: Some conditions might further exacerbate the iatrogenic effect. The age of the child is certainly relevant, as younger and older children may be less affected by the processes described above. For example, a peer-training program, in which boys in third through fifth grades were trained to attend to behavioral cues of intentions, reduced the amount of aggression displayed by aggressive, unpopular boys (Hudley & Graham, 1993).

A two-year program, combining family interventions with peer training of boys identified as aggressive by their kindergarten teachers also resulted in reduced antisocial behavior and increased school success in subsequent years

(McCord, Tremblay, Vitaro, & Desmarais-Gervais, 1994; Tremblay, Pagani-Kurtz, Masse, Vitaro, & Pihl, 1995).

However, these peer-training groups were designed to include a mix of prosocial and aggressive youth, which may be the desired strategy. Feldman (1992) also found that mixing antisocial youth with prosocial youth in interventions was an effective strategy in reducing their problem behavior. Aggregation of high-risk youth, then, may be helpful in middle childhood or when groups also enforce interactions with prosocial children who do not respond with interest to talk of deviance.

Age of the child and format of the peer aggregation may impact the risk of producing negative effects on problem behavior.

Another factor to influence the risk of an iatrogenic effect is the kinds of youth included in the groups. Peer aggregation of depressed adolescents into cognitive behavioral interventions, for example, produces positive effects and statistically reliable reductions in adolescent depression (Lewinsohn & Clark, 1990). Of note, however, is that in this research, youth with comorbid disruptive behavior disorders were not included in the study. Therefore, interventions aggregating youth in the treatment of depression, including those with antisocial behavior, may unwittingly produce increases in problem behavior. A broad view of the developmental and intervention literature would suggest that early adolescence is an especially vulnerable time for peer effects on social development, at least for children at high risk for delinquency.

Research by Chamberlain and colleagues revealed that mobilizing adult caregiving is a critical and viable intervention target for even the most severe adolescent delinquent (Chamberlain & Moore, 1998; Chamberlain & Reid, 1998). Her research compared a treatment foster care model with group home treatment, finding that the former resulted in reductions in deviant peer contact and subsequent self-reported and court-documented delinquency, compared with group home placement.