Youth Support Library

Keynote Lecture Chaired by Diana Birch


Protecting Youth from Harm - Lessons Learned from Adolescent Health.

Robert Blum

DB - I would like to introduce a good friend of mine who has is somebody who I have admired for a long time.  And I am sorry if I sound repetitious because I said this about a number of people today but it is the truth. Bob Blum is one of the people who I discovered when I was doing my first study on teenage pregnancy back in the 80s. I was reading these papers which I was just managing to get from America, it was quite difficult to get papers from America in those days, and this name kept cropping up, kept cropping up and when I first went to a meeting in America I saw him in the flesh I thought, wow, that’s Bob Blum, you know, so I am really proud that he is actually able to come to one of our meetings today. Bob is Professor in Adolescent Medicine from Minneapolis and he has done a lot of work particularly on data bases about young people, I think in Minneapolis they seem to have the largest data base in the world I think on school kids, and he’s done a lot of work on risk-taking behaviours and this sort of thing in young people and over the last few years particularly he’s done a lot of international work and looking at global trends in adolescent health. So I very much welcome Bob Blum.


Robert Blum

Diana, thank you very much, and it certainly is a great treat, a great honour, a great pleasure for me to be here, certainly seeing many friends and colleagues from throughout Europe, the States, around the world and a particular honour for me to be part of not just this conference but a celebration and acknowledgement of the work that Diana you have done and the work that Youth Support has done, it has been a pretty loud and a pretty consistent voice on behalf of young people, congratulations to you, it’s a pleasure for me to be here.

ADD Health - The title probably means little to most. ADD health is the study that’s being undertaken in the United States. It is the largest single study ever undertaken in the United States and I’ve had the opportunity over the last four plus years now to be one of co-investigators on that project. I’ll tell you about some of the things that we have learned. But I want to first put that discussion in a context of what is happening with young people 12 years up and in fact around the world. Because we have an understanding of trends, we have an understanding of morbidity and mortality, we have an understanding of risk factors and we are increasingly developing an understanding of protective factors.

What are some of the demographic trends, what are some of the things that we are seeing? Today 30% of the world’s population are between the ages of 10 and 24 years. In fact the majority of those young people are in developing countries, 83.5% are in mostly countries South of the equator. In the number of countries in sub-Saharan Africa there are 5 times the number of people who are under 15  than there are people over 55. Think about it, in a country like Kenya half of the population of Kenya is 15 years of age or younger. In many developing countries they make up 20 to 25% of population and compare that to France - 13%, Japan - 11%, China - 16%, so we have a skew in young people, and a skew in the developing world. Much of the developing issues of adolescents have come under the screen as a function of child survival. We’ve come to see dramatic improvement in infant survival rates. And so we now have a larger cohort of adolescents for example in sub-Saharan Africa and parts of India, parts of South East Asia than we have had before.

There are also a number of social trends that have a substantial impact around the world, one is migration between countries and that certainly has had an impact throughout Europe, very definitely seen in Northern Europe but the creation of a European community has allowed for much more heterogeneity than existed a generation ago. We see much more migration within countries and not only that - there’s always been rural to urban migration but most of that migration historically has been men. Men who came from the countryside into the city, worked, sent money home and went home once a week, once a month, periodically. But now what we are seeing is more and more young women migrating from rural areas to urban centres. And we see it very dramatically throughout  South America.

Around the world there is a tremendous increasing priority being given to education and while women still lag far behind men over the past generation the rise and increase in education of women have far outstripped that of men in many developing countries. But what you have are young people that are now not in the fields, not in work settings but are being kept in school. You have a whole cascade of events that begin to happen when that starts to happen. You have a shift in the age of marriage because schooling becomes more of a priority and it’s difficult to marry at the age of 11 or 12. Historically early, high infant mortality, high pregnancy rates were a common and often repeated pattern. But now what we are seeing is with the delay in age of marriage and that is occurring across the developing world and the industrialised world as well we are seeing a tremendous rise in the out of wedlock births.

And we have also a portrait in industrialised countries and developing countries alike, where ethnic minorities are disadvantaged, whether it is, the Laps of Scandinavia, the natives of Canada and the United States, or South America, or whether it is ethnic minorities in other countries, the history is told over and over again. Well, there are some of the social trends, some of the mortality trends that we’ve seen, some good news. Mortality in the second decade of life is many countries of the world has begun to decline. We see in the last decade 1980-1990 a 13% decline in the United States, 3.5% in Latin America, but 7.5% in France.

What we’re also seeing is that a number of the trends are beginning to correlate  from across the countries from across the world. For example, we see a reduction in juvenile motor-vehicle deaths, we see that over the last decade throughout all of Europe, all of North America. So we are seeing this decline in juvenile vehicular deaths. What we’re also seeing is that in many countries of the world a rise in violence related deaths, from homicide, from war, from suicide are all continuing to increase. And clearly it’s disproportionately male.

So when we look at suicide rates for example, 1970 - 1986 you see for almost every country of the world suicide rates have increased and increased dramatically, it’s true in Britain, it’s true throughout Europe, the exceptions are probably no longer the exception, Western Germany was an  exception. But since unification that trend has reversed. Venezuela had a decline in juvenile suicide but since Venezuela has gone into an economic tail-spin over the last decade that trend has reversed. What we’re seeing in this is I think a pretty significant measure of social unrest.

Maternal mortality presents a leading cause in many developing countries. About half of all maternal deaths are due to abortion complications. Abortion complications and septic deaths occur only in the countries where abortions are performed in clandestine manner. A second cause for maternal mortality is cephalopelvic disproportion, haemorrhage, toxaemia and sepsis all are associated with maternal deaths. What we’re seeing throughout part of Africa associated with maternal mortality is ritual genital mutilation and increasingly we are seeing this in the United States and I would imagine in Europe as well  as population from Ethiopia, from Somalia and from other African countries where RGM is practised these folks migrate to Europe to Canada and the States we’re seeing now the issues that we never historically had to deal with. And in Eastern Europe high rates of deaths from abortion complications.

Violence and homicide are increasing concerns. Certainly in the United States of epidemic proportion and our rates when they have begun to decline still are in excess of all of the 25 industrialised countries of Europe. In Columbia homicide rates account for 28% of juvenile male deaths, Jamaica is increasingly concerned about gangs and gang violence and gang-related deaths, in the new independent states of the Former Soviet Union homicide accounts have risen 850% -  850% excess mortality. And I remember distinctly when people used to say that homicide was a distinctly American phenomenon. It no longer is. It is a global issue and a global concern.

What are we seeing throughout the world for better or worse, and sometimes it’s for better. The vehicular death trends for example, for better or worse we’re seeing a convergence. with morbidity likewise. HIV sero-positivity 30% of all adults in Uganda, 1,000,000 people in Latin America are HIV sero-positive, half a million people in the United States.

Another trend that we’re seeing that is paralleled around the world is earlier age of sexual debut. 40% of kids in El Salvador and in Brazil have had intercourse by the age of 15; 45% of males in Spain have had intercourse by the age of 15, 50% of all girls in Nigeria have intercourse by the age of 16; the trends and patterns are somewhat different, I mean certainly you can compare Britain and the United States and we see some real differences and subtle differences, in male/female ratios in the age of first intercourse, but overall the trends are very very parallel and they are moving in the same direction with earlier age of sexual debut.

What we’re also seeing concurrent with that is another phenomenon that is just parallel around the world and that is the rise in out of wedlock births. In the United States between 1965 and 1995 out of wedlock births increased from 10%, one out of 10, to 3 out 4, 75%. You could take the graph of increase of out of wedlock births for the United States and take the graph of rise  of out of wedlock births for Chile and put them one on top of the other and they would look identical. In 1970 10% of kids in Chile who gave birth were out of wedlock today it’s 75%, identical to what we’re seeing in the United States. As we have heard Tony Blair’s offices now said that teen pregnancy and out of wedlock births are a major issue for England and here the rates are double that of other countries in Europe.

Throughout the industrialised world over the past decade we have seen a decline in abortion, a clandestine abortion throughout Africa, throughout Latin America, I don’t know as well the data for Asia, but in those 2 continents clandestine abortions are rising and rising dramatically. 2 million abortions are estimated to occur in Latin America annually and for those who are interested in about 6 weeks the Allen Gutmacher Institute in New York will be publishing the chart book on world-wide abortion trends, it’s the first chart book to come out in about 15 years at least, maybe 20 years. And it will document in detail those trends in abortion in countries where it is legal and in those where it is clandestine. In a 6 nation study of adolescents in East Africa between 18% 1 in 6 and 1 in 3 girls knew someone who had had an abortion. Abortion is common, not surprisingly if your option at school is your out to success if you’ve a delay in marriage and if you get pregnant you are left with few options and it isn’t surprising that even given the risks kids would opt for abortion.

Alcohol use rates continue to rise among youth. In Latin America use has increased 400% in the past 25 years, juvenile alcoholism is a major issue in a number of countries. I see that we have here some of our colleague from Australia, 47% of 11th graders in Australia drink at least weekly. Heavy drinking in the United States has steadily declined over the past 4 years but other drug use, marihuana and cigarette-smoking has increased.

Tobacco persist as a major health problem. Not only that but tobacco industry has been targeting, specifically targeting South East Asia, Africa and Latin America where as income increases the sale of cigarettes goes up. You know, it’s very interesting, I’ll be talking in just a moment about the ADD health data in the United States. One of the things that we have seen in the United States, US data however, is that as income goes up overall, take the whole US population of adolescents, as income goes up, cigarette smoking goes down. But we have segregated that, broke it out for ethnic minorities, for kids of Hispanic origin and African-American teenagers and what we started to see was that as for those populations as income goes up, cigarette smoking goes up. And putting in an international content it sort of dawned on me the other day you know, it is the same phenomenon, you get this rise in cigarette smoking with new wealth, you get rise in drug use, and that’s well what we’re seeing certainly in Latin America, until you begin sometime down the road to see a decline.  43% of 18-year-olds in France are regular smokers. 28% in Chile. China is the largest producer of tobacco.

So these are some of the trends, these are the context then, that I’d like to talk about some of the things that we’ve come to understand that protect young people from harm. And I am going to talk about it using US data, because that’s what I have. But I have a strong sense knowing what I do about adolescent health studies in other countries that many of the same factors that are protective in one context are protective in another. Let me tell you first of all a little bit about this study. It was undertaken with the team which was based at a centre for population studies at the University of North Carolina Richard Eugene is the principal investigator, we have collaborators in up state New York which is over there on your right, University of Arizona, Batel, which is a large private research group. In Seattle, Washington, University of Minnesota, and NORC, which is National Opinion Research Centre who actually undertook the study, carried out the logistics of the study. It was a very complicated and a very sophisticated study that started with an in-school sample. And what we did, we identified 80 high schools around the United States, and the high school was defined as any school that had an 11th grade and had at least 30 students, OK. From those 80 school we then identified the feeder school, the middle school, the junior high school that fed into these schools. So we now had diode, a pair of schools, but in fact not every high school has a junior high or middle school, so what we wound up with is a 139 schools that were heart of our original sample and in fact what that represented was about 85%. We went into the schools and we surveyed all the kids who were in the school on that given day. That accounted for over 90,000 teenagers. A whole lot of kids, 90 thousand. We also surveyed a school administrator, like a head-master or principal of the school, so we had a 139 of them and there’s 90 thousand kids. We then got the school roster, the list of everyone registered in the school, because we know that anyone at risk for anything bad, you can name it, is less likely to be in school on a given day. So we wanted to make sure we included those kids as well. So from that 90 thousand plus this other roster we identified a core sample. A core sample we invited about 15,250 kids to participate in the in-home phase of this study. Of those about 12 thousand agreed, so that’s about 80% agreed. Of the kids who agreed to an in-home interview which was an hour and a half in-home interview  - of those 86% had a parent who agreed, almost all of the parents who agreed were mums, probably not real surprising. So we have parent data and teen data.

We also  - and I am not going to be talking about it have a number of fascinating special samples, we in two communities in the United States we went in and interviewed everyone, everyone in the whole community, we know the entire community network from everything, from who lives next to whom to who sleeps with whom. We have a sub-population of higher educated higher income African-American kids because one of the things we tend to do in the United States very problematically is use race as a proxy measure for income, we talk about whites this and blacks this as if it were something to do with colour of one’s skin. So we had the ability to desegregate that. We had 800 sets of twins in that study for genetics, We have a disability sub-sample, we have a Cuban sub-sample, we have a Philippino sub-sample, we have many sub-samples that are unique in this group. But what I’ll be talking about is based on the core sub-sample or the core sample. And the core sample is a representative sample of all kids in the United States. Just to give you a sense this is what the ethnic breakdown is of that sample.

One of the things that we looked at. What I’ll be talking about is 8 risk behaviours. And the factors associated with increasing risk and the factors associated with demising risks for these 8 behaviours emotional distress, suicidal thoughts and attempt, cigarette use, alcohol use, marihuana use. Violence involvement, age of sexual debut or first intercourse and pregnancy. These are the 8 outcomes, what is often talked about as risk behaviours. Then we were interested in what are the things that are associated with protection. Well, we looked at family factors. Family factors such as connectedness, the relationship young people have with a parent, parent presence in the home, we looked at 4 times of the days, on waking, in the afternoon, dinner time and bed time. Activities with parents, going, kicking around the football, going shopping, taking a walk, watching television, things of that nature. Parental expectations for school, completing school, higher education, doing well at school. We looked at families suicide attempts, we looked at families, we looked at family income, family structure, like one- parent and two-parents families, things of that nature.

We looked at a whole set of school factors asking what is it about schools that make a difference in the lives of young people. We again looked at connectedness, and I’ll come back and talk about it more specifically in a moment, we looked at grades, we looked at how many kids are held back and what’s the impact of being held back in school, not passed on the next year is, we looked at teacher characteristics, such as whether they are male or female, whether they got higher education degrees. We looked at the rules schools have, what are the rules about drinking, what are the rules about pregnancy, what are the rules about sexual behaviour. I don’t know if in Britain and in Europe there is the same fetish that many institutions in the United States have, but there is sort of this notion that there ought to be a rule in that somehow a rule will have a significant impact on behaviour. And we looked at parent involvement in school.

We also looked at the whole set of individual factors: self-esteem, maturational dis-synchrony, being early mature or being late mature, being out of synch with your peers. We looked at employment, being paid for work, we looked at sexual orientation, school performance and learning problems, gender, ethnicity age and a gazillion other variables as well.
What are some of the key findings? Well, turning first to family, what are the things in family that mater. In the United States recently there has been much press given to a book written by an individual called “The Nurturence Assumptions” that claims “parents don’t matter”. All parents provide are genetic makeup and a roof. I would strongly suggest that is not true. What we saw is that for every single risk behaviour that we looked at independently kids who felt connected to their parents, they felt that they had a relationship with their parents, were much less likely to participate. They smoked less, they had later age of sexual debut, they attempted suicide less, they drank alcohol less, they did every negative behaviour less. That’s connectedness. And that connectedness was not predicated on whether the parent did something with their kids, whether they took them places, did activities with them and in fact what we found is that it didn’t matter.

In fact for emotional distress what we found is that for all the connected teenagers decreased levels of emotional distress. Now adults had a hard time understanding why that trend might be true but kids had no problem at all. We actually went out then and had focus groups with young people and said, what does that mean, how do you know when you are connected. And the examples we heard were wonderful. You know, my dad does not say, who was that guy you were out with on Saturday night?, he says, You went out with jimmy on Saturday night, you had a good time? He knows who I went out with. My mum says, how did you do on that test last Thursday, the math test you had, I’ve been wondering about it. There is a note on the  refrigerator, I am going to be home late but made a snack for you. The neighbour stops over to check in on me because my mum does not get in until 5.30 or so. My mum calls during work after I get home just to make sure I am at home and to see how my day was, we always have dinner together. These are endless examples that aren’t predicated on physically being present all the time. But there is this sense that the parent is watching and the parent cares. And I will tell you it is more powerful in reducing risk than anything. And it does not diminish for all the teenagers. It in fact is no less for 16-17 years olds than it is for 13-14 year-olds.

We looked at availability as I said at key times during the day and while being present more is better than being present less there is no preferred time of day. And this is particularly important I think again perhaps uniquely in the States, but I don’t think so, for working women, where there is this sense of guilt that I am not home until 5.30 6 o’clock, being home after school was no more sacred than being home in the morning or dinner time and the evening, and in fact some data coming out of more recent analysis is suggesting if there is one time of the day that perhaps somewhat more protective it’s around dinner time.

Parent expectations for school is profoundly protective. Parents who expect kids to complete school and give them that message day in and day out, these kids smoke cigarettes less, you want a teen pregnancy prevention programme - there it is, in school expectations, and violence prevention, these kids are involved in violence less and they understand their parents expectations around school.

Parents expectations about sexual behaviour.  If a kid believes that her or his parents think that for them to have sex now at this age is wrong they are less likely to have intercourse. Now what we have also looked at recently because as I said we have a capacity to look at parent data, OK, and to look at kid data, so an interesting question to  know what a parent is saying they say and what a kid is saying they say and what’s the inter-correlation between the two. Well, the inter-correlation between the two is pretty low it’s about point .15%. Now one of the things that is really interesting is I think is that mums are pretty smart. My mother told me that but you know she did not have the data to substantiate this so I didn’t really ever much believe it. But it’s true. The degree of accuracy that mothers have about their kids sexual behaviour is awesome. With more than 90% accuracy, and this is independent of what I as a mother believe. I may be absolutely a fundamentalist who believes that you don’t have an intercourse before the age of 80, I maybe a social liberal, my personal beliefs I will tell you do not significantly affect my eyesight when it comes to seeing what’s going on with my kids. But on the other hand there is a big gap between what parents say they say and what kids hear, a big gap. And it says to me I think in a ways some very important and some very fundamental questions about communications. And it raises some very fundamental questions I think about direct versus indirect messages in both parent-child communication and in health education, hopefully we can talk more about it a little bit later.

We also found that in households where there is tobacco whether or not a parent smokes the risks of smoking go up dramatically. In households where kids have access to alcohol they drink more. Now I have had this conversation with some of my friends and colleagues who are from France and from Switzerland and other places, drinking clearly in a country like the United States in adolescents has some very different implications when you are a driving age of 15 or 16 where in the countries where you have a driving age of 18 in where you ride cars instead of walk. On the other hand there is  strong evidence from what we are seeing that kids who are exposed to alcohol early learn to drink. They don’t become responsible drinkers they become drinkers. Much the same way as people who are exposed to guns early don’t become responsible gun users, they become gun users. Not only that, kids who are exposed to guns earlier have higher suicide attempt as well as higher violence perpetration. So exposure to these substances predisposes to risks.

The school environment counts. But actually only one thing did we find that was really protective and that was connectedness. That was the connectedness that a young person feels with the school. And that connectedness did not depend on how many kids there were in the school, it didn’t depend on the truancy rate, it didn’t depend on how many teachers had higher education degrees or how many parents were involved the school. And it didn’t depend on how well you did in the school. School connectedness is not another measure of your grades, in fact the inter-relationship is not tremendous. What it is, it is a set of two things: one is that there is at least one adult in that environment who cares. And two is that I am treated fairly in school. And kids have an abiding sense of what it means to be treated fairly. 

And then we looked at individual characteristics and what we found was working more than 20 hours per week was associated with every negative risk behaviour we looked at. Kids who work for pay more than 20 hours a week were more involved with alcohol, with cigarettes, had an earlier onset of intercourse, every behaviour. We found that kids who are doing poorly at school, who have attention problems on school, we found that kids who are held back in school and young people who are physically out of synch, early and late matures are all at much much higher risk for negative outcomes. Based on all that we have seen in these data as well as other data would suggest that at least in the US context school failure is a major public health problem. Kids who are doing poorly in school pay a high price not just economically in their ability to get work later on but a high price now in their health behaviours as we pay that price as well.

The things that seem to have little impact: school rules. School rules don’t make a difference, We looked at school rules in every way, shape and form and we can’t find a school rule that significantly impacts behaviour.

What parents say they say to their teens about sex does not seem to make a difference and that’s what I was talking about before, that gap between messages that get through to kids and messages that go through one ear and out of the other. And I have a sense that one of the necessary preconditions for a message to be heard that there is this connectedness. Because without that connectedness it’s not going to happen. It’s not going to be heard.

The type of school attended, we’ve had all sorts of types of schools that don’t seem to make a difference.

Well. We have I think some clues as to factors that protect young people from harm. Certainly we have a decade probably a generation now of prevention research to know full well that that is a myth. There are many things that work and many things that we can  do. But the reality is also when you look over the landscape of prevention programmes mostly what you see are failures. When there have been rigorous analysis of pregnancy prevention programmes in the United States I would say generously there are ten effective programmes. When you look at drug abuse programmes probably less than 10. Violence prevention programmes there are few that work and a few very dramatic programmes that work. But there are large numbers of programmes where we have invested millions of dollars that don’t work.  Why? Some fail because they have no theoretical foundation. I can’t recall who said it, but a phrase that I really like, that there is nothing more practical than a good theory. If you run a programme without a theoretical foundation the likelihood that it’s successful is low. Two is that many programme don’t build on the research that’s been done. Not only they are atheoretical, they don’t have a research base. Three, we often don’t evaluate in any rigorous kind of way what we do. A professor of mine once said that most evaluation is based on wing flaps per pound of bird seed. You know, you have your pound of bird seed and you count how many wing flaps occur before the bird seed was eaten. Well, we often do the same. We count how many people come into our service and use them , how many left-handed kids, right-handed kids, kids that came from that area, but do we ask, does this really matter? Programmes that don’t succeed are often unidimensional. They focus on one thing, they don’t focus on the broad set of complexities, that really are what’s so important. And they tend to focus on problem reduction, doing away with reducing cigarette-smoking, doing away with reducing pregnancy, you name it, you can slot it in. But most kids like most adults don’t want to be fixed, they want a thrive.

A colleague of mine Karen Pitman says, problem-free is not fully prepared, and I think that’s so true, you know, no one has ever asked me, hey, Bob, how are your kids doing, I’ve never said, they are really doing great, you know. They haven’t killed anyone this year, none of them are hooked on drugs, none pregnant, as far as I know they are sero-negative, so they are really doing great, you know, that’s not what I want from kids, maybe that’s what you want from yours, but that’s not my goals, my goals go beyond that. Our goals have to go beyond that and effective programmes do go beyond that.

Effective programmes include parents and bring parents in because they realise that the effect of role of families do not diminish over time. They strengthen educational involvement, because they understand that kids’ success in school is tied not only to their future but tied to their presence, these programmes understand that you have to create opportunities. Christine Lucar a contracepting researcher from Berkley, California, talks about contraceptive use is like money in the bank: you have to be worth investing it, if you have no future, you have no economic opportunities, you don’t put money in the bank and you are not going to contracept. And effective programmes understand that it’s not just dealing with problems, but it’s enhancing young people where their effort needs to lie. Effective programmes understand they need to create conditions for social  bonding. They need to create opportunities to bring young people in and to give them meaningful roles, not just as people to be fixed and worked upon, but as team players and collaborators.

The young people need skills to be successful, we saw such a wonderful demonstration today over the lunch hour from a group of young people from Israel, youth actors, who are crafting what they are teaching, have the skills to do it and huge recognition and reward for a job well done. It’s this combination that leads to success. We know a lot about what makes programmes work, we know a lot about what’s put young people at risk, we know a lot now about the things that protect young people form harm. For us the task is to put it together. Thank you very much.

Diana B.: Thank you very much, that was a really wonderful presentation, you’ve covered so much ground. And as you said we have a lot of knowledge now about what young people are doing, and the problems and perhaps what families are doing wrong, and maybe as you say we now we need to go on and put it together and actually make something of it .Would anybody like to ask some questions, we’ve got just a couple of minutes.

Question - How do we address the question of motivation in teachers?

Robert Blum: Did everyone hear the frustration, did you hear the details as well? Let me address, I could share your frustration, but I will tell you why I don’t. I don’t because the World Bank for example has said you keep a young girl in school till the 7th grade, no matter how terrible that school, no matter how terrible the teachers, no matter how much maltreatment goes on in the school. And her outcomes are much better. Simple keeping kids in school, are better schools better? - Yes, are more motivated teachers better - yes, but the mere fact that the kid is at school does make a difference. One.

Two is yes, families are sometimes falling apart and families are reforming and redesigning, you know in the United States in 1955 2/3 of all families were an idealised family of 2 parents and 2 children. Today in the United States 7% fit that profile, only 7%, OK! So. We have numerous kinds of families, the premise that I would work on is two-fold: one no matter what else is happening most parents want parent want good things for their kids. They maybe have 2 pesos per that they make, but they want good things for their kids. They may have not a clue how to get it. And two is when most kids don’t want to be fixed most parents work very hard, whether they in the street pan-handling or whether they work in a factory, they work very hard. So they not going come to learn things at the end of the day, they are just too tired. But what experience certainly is showing in numerous places is that parents will come to celebrate what their kids do. And programmes that bring parents in not to work on them, not to fix them, but to bring them in to celebrate what their kids do, parents do come, and there examples not just from the States  but from all over. It isn’t en easy process, admittedly it’s a very challenging process, but my starting point is parents they want good things for their kids so we starting at the same point. They might not have a clue how to get there and what they might think is a good thing and what you might think is a good thing might be different. And we might have to sit and really negotiate it and give up some of our things.

The other thing is and it is very tough, is that we have to be able and willing to de-professionalise, to off our jackets, to take off our fancy clothes, to roll up our sleeves and to really work. Woman who’s done some great work in the United States Elizabeth Shore says, you know, she tell a terrific story of a social worker and comes and knocks at the door at this woman’s house and she said, “Who are you?”, and she said I am so and so, I am a social worker, - “I don’t need another social worker, all I have is my life is filled with social workers, I don’t need a social worker, get out, what I need is someone who’d scrub my kitchen.” She said, “OK, let’s start at the kitchen.” She went in and scrubbed the kitchen, and when she was done she said, “Do we go to the living room or do we go to the bedroom, what do we scrub next?” And when they were done scrubbing all the floors, she said, “Can we talk now?” That’s de-professionalising, that’s willing to be where people are at. You’ve got to be willing to be where kids are at.