September 1996
SAN FRANCISCO — You can preach to kids until you're blue in the face; it won't change anything, said Kenneth Ginsburg, MD.
Teens need more than facts to help them change behavior; they need the tools to change, explained Ginsburg, who is assistant professor of pediatrics at the Children's Hospital of Philadelphia.
"We believe that if we give them information, if we educate them, then they will change their behavior. Does this work? No," he said.
Adolescents are making the transition from childlike to adult thinking. Children deal with concrete ideas; they cannot consider the future; and they don't recognize ulterior motives. This places them in danger of being fooled by kind words. Adults think abstractly; they consider future consequences; and they recognize the ulterior motives of others.
Adolescence is the process of changing from childhood to adulthood. Along the way, the adolescent experiences life, fails and learns.
"I'm a 14-year-old girl, and a guy says, 'If we just do it once, I'll love you forever.' The girl says, 'I saw that on "Beverly Hills 90210" — that's fabulous!' She gives in, and he's gone the next day, and you know what? She learned something. She learned a really important skill — to understand what a line is."
The trouble is that today's world is faster and more dangerous than the one many physicians remember in their youth. "We cannot allow our youth to learn by experience. We have to talk to them in ways that move them little steps of the way. You can figuratively make them go through what I call a 'cognitive ah-ha' experience, so that they won't have to get hurt by that 14-year-old guy, so that they won't have to be shot to know that carrying a gun might put them at risk for death," he said.
Sex is a big issue. Although Ginsburg favors abstinence among teens, he is a realist. If a teen is practicing abstinence, then he or she needs to be able to say no and mean it. The teen also should know that there are other sexual experiences besides intercourse. If a teen is sexually active, he or she needs to know how to negotiate condom use.
They need to realize they must use a condom — every time. If asked, a 16-year-old will admit to using condoms sometimes. So, how does he decide when it's safe to go without one? He will tell you that his partner looks okay; he trusts him or her.
"This is one of the main reasons we're losing the fight about condoms: when a condom is pulled out people are saying, 'What, you don't trust me?' It is an insult. We have to reframe the social agenda, just as we did with drunk driving, so that when you pull out a condom someone will say, 'thank you for respecting me.'"
Get the teen to think about this. Ginsburg will draw a diagram for the teen. "This is you, and this is this girl you're sleeping with here. How many people can you get pregnant? He says 'one,' and then you say, 'how many people can you catch diseases from?' He says 'one.'
"I say, 'okay, but suppose this person had sex with three people before you? Now how many people?' He says 'four.' 'Okay, but suppose this person had sex with two people, this person had sex with two people, this person had sex with 10 people. Now how many people can you catch diseases from?'"
Eventually, the kid will get the "cognitive ah-ha" look. "Exactly, you trust your girlfriend, but do you trust this guy?" Ginsburg asks pointing to one of the stick figures in the diagram, "because you are sleeping with him." Ginsburg reiterates that people should use condoms every time they have sex. "Then I say, 'by the way, let me tell you something else: AIDS is invisible. Your girl could have it and not know it for 10 years. She's not lying to you; she just doesn't know.'"
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This is an abstract idea — the epidemiologic transmission of AIDS. "How do you do it? You do it the same as you do it with all cognitive experiences. You take an abstract concept and break it into small, concrete steps. Then you have created a potential for a new recognition, which is the first step toward behavioral change."
The next step, refusing sex, requires skill. Ginsburg said there are three categories to all refusal skills.
First, learning how to say no. Second, reversing the pressure. Third, coming up with something else to do.
Kids need to know how to say no. This is critical in a sexual situation. "What does no mean? No phrased in a passive way or joined with a smile can mean yes, no can mean push me further. This is an absolute set-up for date rape," he said. "When the word no does not categorically mean no, when the word no is a start-up for negotiation, you have lost. Kids must be taught how to say 'NO, end of negotiation.'
"I do this in my office all the time, and I'm sure I will get in trouble one day when the president of the hospital walks by and hears girls shouting no at me, but it is an important skill to have."
Teach kids they can avoid situations by coming up with an alternative. Parents can help with this, he said. Parents and children can have a code. If the child uses the code, the parent puts his or her foot down and takes the blame for spoiling the teen's fun. It is not easy for a 15- or 16-year-old to say to a friend, "I am ethically, morally and spiritually opposed to your behavior — I will not participate." But very easy to complain, "My mom's always ruining my life."
He explained, "You're in a situation you haven't been able to get out of, you call your mother and you say, 'Mom, it's 10:00, you said I had to call, what's up with that?'
"'What's up with that' is the code word. 'What's up with that' to the mother means she is to say, "You were supposed to be home two hours ago! Where the hell are you?! I'm coming and picking you up right now!"
To which the child says to his friends, "My mom's mad. I have to go." He's out of the situation without losing face with his friends.
Kids need to recognize how drug dealers manipulate them. "You get the drugs for free. Why do the 10- to-12-year-olds think they're getting drugs for free? Because they're nice, they like me."
Ginsburg compares these "samples" to the coupons their mothers use in the store. "I get them to understand the abstract concept of business and why people give things away free sometimes, and then I go back to the drug dealer."
Ask what happens to drug dealers. "In the suburbs you will hear that they get rich," Ginsburg said. "I have never had an inner-city kid tell me that drug dealers get rich. They always tell me they die or go to jail. The drug dealers in the suburbs do get rich. They don't get caught, they're not involved in the world of violence. In the inner city it's a short fix, and you die or you go to jail.
"I say, 'So listen, if you deal drugs for this guy, who's going to go to jail? Who's going to die?' The kid says, 'Me.' So why is this drug dealer being nice to you? The kid usually will make the transition, and when he makes it, I'll say, 'Exactly, of course this guy's being nice to you. You're catching his bullets, you're doing his jail time, and you're giving him the money!'"
Violence is an area that kids need help in negotiating. Fights escalate, and they can be stopped. "Fights often begin by someone calling another a name. Often a fight can be avoided by giving someone respect. You can just say, my fault, just back up, my fault, but the point is just give them respect, because that's what they need, or make a joke and be funny."
If a kid gets in a fight, he or she can still keep it from becoming a death sentence. Ginsburg tells kids don't win big because that just means the other kid must retaliate.
"A weapon of any kind will start the cycle of retaliation. Kids carry weapons because they're scared. They believe that guns confer safety." Talk to kids about carrying weapons. Help them realize that they might not be safer because they have a gun, that they actually might be in more danger.
Review a fight scenario without a gun. How does it work? How does it end? Review a fight scenario with a gun. What happens? Eventually someone is going to pull out the gun, and someone might die.
"Almost every single kid I've even done this with gets that, that having a gun makes them more likely to get killed. Furthermore, once they get that, I teach them that posturing, which is when you look like you're carrying a gun, puts you at greater risk for death. Having a reputation of carrying a gun means that if someone messes with you, they're going to kill you, means if they want your jacket, they have to kill you for it," he said.
You can take abstract concepts and break them into concrete, understandable steps. If you consider adjusting your counseling style from preaching facts to working toward making youth recognize these protective, abstract understandings and teach them skills to achieve healthier behaviors, you can really make a difference in their lives.
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