Rachel Skinner: [00:00:02] Welcome, everyone, to this month's Wellbeing Health and Youth webinar. I'm Professor Rachel Skinner and I'm the Deputy Director of Wellbeing, Health and Youth [WH&Y], which is an NHMRC Centre of Research Excellence in Adolescent Health.

Rachel Skinner: [00:00:26] Before we get started, I just want to acknowledge the funding support of the NHMRC and the wonderful contributions of all of our research partners in the various universities across Australia who partner with us, as you see on the slide. 

Rachel Skinner: [00:00:45] We also acknowledge the traditional owners of country throughout Australia and recognise their continuing connection to land, waters and culture. We pay our respects to their elders past, present and emerging. 

Rachel Skinner: [00:01:05] I'd like to draw your attention to our website, WH&Y.org.au, as you can see on the screen, please have a look at it from time to time. And just to note that we recently got a new section, the Community of Practice section on the site, and it's filled with a lot more resources, publications, achievements of our researchers and many affiliates. It also has all of the recordings of these webinars, if you didn't get a chance to watch them or you'd like to browse through what has been recorded. So it's developing a valuable resource there. 

Rachel Skinner: [00:01:53] A little bit of housekeeping, your microphone has been muted and your video has been switched off. But you can use the chat function just to communicate between the other listeners, the other audience members. And you can also ask a question of the presenter up at the top. As you can see, there is a different icon for that, but you still type the questions at the bottom of the panel, and that indicates that it's a question for the presenter. And after tonight, this is recorded, you will be able to watch the webinar through our website and read the transcript as well. It's also time stamped if you want to go to specific sections, for example, where a question was asked. 

Rachel Skinner: [00:02:52] So, now it's my great honour to introduce Dr. Jennifer Marino. Jen's a Wellbeing, Health and Youth Postdoctoral Fellow and also a Senior Research Fellow in the Department of Obstetrics and Gynecology at the University of Melbourne and the Royal Women's Hospital. Jennifer conducts both population and clinic-based research in women's health, with particular emphasis on sexuality and reproductive health. And her population-based research concerns risk-taking behaviour in particular in teenagers and young adults. So, thank you Jen for your time and great knowledge on this topic. 

Jennifer Marino: [00:04:13] Thank you so much, it's a pleasure to be here, and of course, pay my respects to elders past, present and emerging. I'm coming to you from the Wurundjeri people of the Kulin nation and I also pay my respects to any Aboriginal or Torres Strait Islander or other indigenous peoples who may be listening today. Thank you very much for having me.

Jennifer Marino: [00:04:37] I'm Jen Marino, and I'm going to talk to you a little bit about changing our approach to risk-taking in adolescents. Speaking of housekeeping, I have a vocal disability. That means that my voice is prone to cracking and breaking and sometimes sort of fades in and out a little bit. It doesn't hurt. It's not painful. it doesn't indicate any emotionality on my part, so please don't be alarmed. I find it easier for audiences if I go ahead and actually address that up front, because I've watched people sort of gradually becoming more and more concerned that I was maybe going to get a little worked up. So don't let it stress you out. And maybe my voice will behave itself this time, but maybe not.

Jennifer Marino: [00:07:15] Well, to begin at the beginning in 1920. The founder of Yale School of Public Health, Charles Edward Emery Winslow, defined public health as the art and science of preventing disease, prolonging life and promoting health through the organised efforts of society. My field, public health epidemiology, is all about measuring and mitigating risk, preventing disease, prolonging human life or promoting good health. When we quantitate these, it's in the language of risk. But what is risk? During my training as an epidemiologist, we defined risk as the probability of a negative health event. More recent definitions of risk acknowledge that risk is not restricted to negative outcomes. The mathematics of epidemiology has always been indifferent to the positive or negative character of the event described. Relative and absolute risk are about the probability of the event, not whether it's bad or good for the person experiencing the event, but the language is really just starting to catch up. The more recent of these epidemiologic definitions is more even handed: instead of immediately providing an example of a negative outcome, the definition is explicit, but the event can be bad or good.

Jennifer Marino: [00:10:07] So, recent definitions of risk acknowledge that risk isn't restricted to negative outcomes. Similarly, ISO, the International Organization for Standardization, is the international body that sets the world's voluntary technical standards related to industry and commerce. ISO has defined everything from the standard speeds for photographic film to the requirements for organisations conducting market research to safeguards for access to water during a crisis. The ISO 31000 Risk Management Standard provides common guidelines to manage risks that can be used by any organisation and applied to any activity, including decision making. The standard, which necessarily uses the broadest possible definition, specifies that risk is the effect of uncertainty on objectives, where such effects can be positive, negative or both, and can address, create or result in opportunities or threats. So the broadest technical definition of risk now recognises that risk is about the element of uncertainty, not whether the event produces a positive or negative outcome. 

Jennifer Marino: [00:11:22] There's been a similar evolution away from negative framing in health promotion. Much of the health promotion for young people has been designed within a deficit model. In the general case, a deficit approach identifies a problem that needs to be fixed or a need that must be met. In the specific case of risk-taking, the deficit approach says that preventing or reducing specific problem behaviours and health risk behaviorus disrupts a vulnerable person's trajectory to illness, injury, disorder or other health or social harm. Interventions within the deficit framework are meant to bring a child or adolescent who's missing the mark back to normality, fixing the person in their behaviours will fix the problem. The deficit framework has certain advantages, it makes for easy storytelling to funders and stakeholders, but it fails to take into account the complexity and nuance of human behaviour and its context.

Jennifer Marino: [00:12:19] In education and health promotion, there's been a shift towards asset or strength-based approaches. These refocus from fixing deficiencies to identifying assets available at the individual, family, school and community levels, including contextual assets. Those assets available to build up the young person and protect them. Strengths, opportunities and resources offset the negative factors to which a young person is exposed. 

Jennifer Marino: [00:12:46] Positive youth development frameworks take asset models a step further. Positive youth development, as summarised by Professor Richard Lerner of Tufts University [Massachusetts, USA], approaches youth as resources to be developed. This perspective embeds youth and communities and economies. To quote a systematic review from Youth Power, positive youth development centres on building skills, fostering healthy relationships and supporting youth to be active partners in development efforts. It suggests that if young people have the knowledge, skills and support they need, they will thrive as adults, enjoy good health, succeed economically and make meaningful contributions to their communities. The principles of the framework have been variously articulated but commonly share the intention of building up four or five features in young people, sometimes summed up as the five C's: competence; confidence; character; connection; caring. In recent years, these have been supplemented by another C, contribution, as into one's community. 

Jennifer Marino: [00:13:56] However, returning to our topic. Generally speaking, all of these frameworks still assume that risk-taking is necessarily negative. Both models are framed in terms of risks as negative rather than risk as a neutral quality based on uncertainty. So trajectory is still from behaviour to outcome with risk-taking and assets, opposing forces that push their trajectory from good to bad outcome, interrupting risk or both bolstering assets will change the trajectory. 

Jennifer Marino: [00:14:29] Now, let's put that aside for a moment and talk a bit about brain biology. The adolescent brain has reached its full adult size and contains more grey matter, neuronal cell bodies, than the adult brain. However, it contains less white matter, the synaptic tissue that connects the areas of grey matter together, connects the functional pieces of the brain. The adolescent years are a period of reorganisation in the brain, growing new white matter, pruning and restructuring connections between different brain areas. The accumulation of white matter over adolescence progresses from the back of the brain to the front. The limbic system is found at the back of the brain, lizard brain they sometimes call it, and is the seat of emotional motivation. The front of the brain, the prefrontal cortex, is the seat of cognitive motivation. The limbic system is essential to sensation seeking and reward processing. Sensation seeking is the desire for new experiences that are thrilling, exciting or if you prefer, autonomic arousing. There's a spectrum of sensation seeking. I'm on the end that likes quiet and predictability. My friend Elizabeth is on the end that likes leaving normally functioning aircraft while they're still above the cloud deck. She loves to leap out of airplanes, with a parachute mostly. 

Jennifer Marino: [00:15:58] When we consider reward processing, there's individual difference in how people detect, respond to and seek out positive stimuli, the things they find pleasurable. Reward processing is central to learning and to goal-directed behaviour. It's also central to addiction. The prefrontal cortex, in contrast, is central to executive function, particularly self-control, self-regulation. Self-control is the ability to inhibit behavioural impulses and thoughts, and reciprocally impulsivity is the inability to inhibit those impulses. Impulsivity is about taking action without much conscious thought or planning. Impulsivity isn't necessarily associated with sensation seeking. One of the reasons I like a lot of routine and don't like to throw myself out of airplanes is that I'm less likely to be startled into doing something thoughtless because I'm a more impulsive person, I tend to damp down my sensation seeking. I once jumped down onto the subway tracks to pick up something I dropped without actually thinking about how I get back up, how I'd avoid being hit by a train. I was a sober, well rested and fully grown adult. I'm just a little impulsive and I acted before I thought. My friend Elizabeth would never. 

Jennifer Marino: [00:17:23] So to recap, the two systems in what we call the dual systems model are the limbic system, which controls reward processing and sensory sensation seeking, and the prefrontal cortex, which includes the machinery that manages executive function, decision making, learning, impulse control, self-regulation. In adolescence, the limbic system is fully developed, but the prefrontal cortex still has some cooking to do. And the connection between them takes some time to fully develop. So adolescents are, as a rule, inherently sensation seeking. They're exquisitely attuned to reward, but they're still developing their impulse control and judgment. With practice and maturation, the healthy adolescent brain can switch back and forth between emotional motivation based, as we said, in the limbic system, and cognitive motivation based on the maturing prefrontal cortex for decision making, depending on goals. This flexibility enables the daring, exploration and social interaction required for development while still permitting thoughtful decisions. Development of this capacity is individually variable, and it depends on sex hormones, environment and other influences we haven't necessarily fully identified yet. 

Jennifer Marino: [00:18:46] So to sum up, developmentally, adolescence is normally a time of exploring boundaries and seeking new experiences. Risk-taking behaviour is a central feature of normal adolescent development. Adolescents have to pursue new experiences and learn by experimentation in order to achieve adult independence. And they have to engage deeply with peers and take social risks in order to develop adult social competence. But risk-taking also contributes to most morbidity and mortality in adolescents and young adults, including dangerous driving, substance use, interpersonal violence, sexually transmitted infections and, for girls, pregnancy and birth. Worldwide, alcohol and drug use are leading risk factors for disease burden in adolescents and young adults. And in Australia, tobacco use is the leading risk factor for lifetime disease burden. Globally, 70 percent of preventable deaths in adulthood are linked to long standing patterns of health risk behaviour originating in childhood and adolescence. In Australia, road crashes are a leading cause of death in adolescents and young adults, with injury of all types accounting for 68 percent of years of life lost among males and 59 percent among females. But most adolescents mature unscathed, with the worst outcomes affecting only a few. And those few tend to experience multiple negative outcomes in multiple domains. This raises the questions. Is there a way to identify the most vulnerable? And can we perhaps identify different patterns of risk-taking to target our interventions more usefully? We know that risk-taking tends to cluster in individuals, and in particular in young people, sexual and substance risk tend to co-occur. This coincides with clinical wisdom about vulnerable youth. But we don't know what other patterns hold or what the longitudinal development of these patterns is. 

Jennifer Marino: [00:20:53] So, Stream Two of the WH&Y CRE is called Pathways and Costs. In that stream, we have two projects going on right now to try to answer some of these questions. The Raine study was established in 1989 at Perth's King Edward Memorial Hospital for a randomised controlled trial of frequent ultrasound. 2,900 pregnant women were recruited from the maternity services at King Edward and most of the nearby private practices, so it's a snapshot, really, of almost all the pregnant women in Perth at that time. Data were collected at 18 weeks and again at 38 weeks, so close in the middle of the pregnancy and close to the end of the pregnancy and again at birth. The 2,900 pregnancies resulted in 2,868 live births with data collected for the whole cohort at that 18 and 38 weeks and then about every other third year since. The Raine study has grown to be a multigenerational study following not only this group of now young adults called GenTwo, but their children GenThree, their parents GenOne and their grandparents GenZero. And before we leave the slide, I always sort of have to say the Raine study isn't an acronym and isn't named after raindrops. It's named after Mrs Mary Raine, who's pictured here. She was a self-made hospitality and real estate mogul in Perth, and she established the Raine Medical Research Foundation, which funded and continues to fund the Raine study. I tip my hat to her. Without her, we wouldn't be here. 

Jennifer Marino: [00:22:32] Raine is a rich resource with a broad array of data items collected about the original GenTwo participants. Over 70,000 measurements and a variety of domains - socio demographic, environmental, cardiometabolic, endocrine, psychological and behavioural - collected from gestation to, as I said, young adulthood, almost age 30 now. This includes some risk-taking behaviour, initiation of sexual behaviour or substance use behaviour, driving, as well as a broad array of information to provide context, including housing and neighbourhood details and schooling. And there's also considerable data about the individual and family to provide context. This is only the standardised instruments and measurements collected for these particular characteristics listed here. There's also extensive purpose-designed data collection from other major Australian data collections like the National Secondary Students and Sexual Health Questionnaire and LSAC (Longitudinal Study of Australian Children).

Jennifer Marino: [00:23:44] Using these rich data, we actually intend to take a very close look at risk-taking in Raine. This is the model we'll use to guide our analysis. We hypothesise that risk-taking patterns are determined in part by development of the capacity for self-control, which is set by early life environment and subsequently contextually modified by individual family, school and neighbourhood variables. We also think that clusters of risk behaviours that occur across multiple domains like substance use, sexual health, driving risk, self harm, form a pattern of negative risk-taking that's characteristic of a neurodevelopmental problem and that it ends up in a range of poor health and social outcomes, again clustered within vulnerable individuals. However, we also all know an individual or maybe more than one adolescent who've managed to rise above the adverse circumstances of their early life and early childhood and have normative or even positive outcomes in adulthood. So we think that there's also a pattern of resilient risk-taking that carries people forward to normal or positive outcomes. And how do we propose to look at this? We'll use the Western Australian Data Linkage System, or WADLS, as it's fondly known, to link a range of Western Australian government datasets with hard outcomes to the Raine cohort. We’ll relate those outcomes to patterns of risk we've identified in Raine and then we'll look at predictors and mediators of these pathways through time. My colleagues at Macquarie University, Deborah Schofield and Patrick Graham, will measure health economic outcomes to calculate the cost to society and the impact to early intervention. These are some of the outcomes we're examining and the databases from which they'll be gleaned, as you can see, these data will provide extensive information about outcomes like sexually transmitted infection, teenage pregnancy, self-harm, suicide, road-related injury, road crashes, other injury, educational attainment, and justice system encounters.

Jennifer Marino: [00:26:12] But you may find yourself wondering how this moves us away from a deficit model. Well, when I started thinking about what constitutes positive risk, because I have throughout this been framing this in terms of negative risk, I realise that the way we commonly think of risk is in terms of the potential for reward versus the potential for harm. Dr. Natasha Doyle of the University of North Carolina at Chapel Hill and Professor Laurence Steinberg of Temple University in Philadelphia, have been thinking, it turns out, along the same lines, and their definition is that a risky act is a behaviour for which the likelihood of its outcome, good or bad, is uncertain, with high-risk behaviours, evincing greater variability in and uncertainty about the outcomes. It's very reminiscent of that ISO 3100 definition, these definitions are value neutral with respect to outcome and to the pathway by which we reach the outcome. The uncertainty requires a decision and an evaluation of the likelihood of different outcomes, positive and negative. Whether the decision making is based on cognition or emotion, we entertain that prospect of benefits. The risk is defined by the range of potential outcomes. And in reviewing the literature about positive and negative risk-taking, Duell and Steinberg identified three major characteristics that differentiate the two kinds of risk. Positive risk-taking they noted carries benefits, the individual wellbeing carries only mild potential costs and is socially acceptable and legal. 

Jennifer Marino: [00:27:56] So when we think about this lower right corner of the model I showed you a few minutes ago, we're not actually doing great justice to those possibilities. I wonder if we can maybe do better to characterise these outcomes. Is there more nuance? How can we define adult success? We certainly have informal definitions already. It's how we guide our planning, whether we're parenting or teaching or devising policy. But there's surprisingly little empirical data out there. Investigators of the US based Search Institute have recognised this gap and developed consensus dimensions of successful young adulthood. Shown here, you'll note that they're even broader than our categories of normative outcomes, if considerably more positively oriented, but there's considerable work remaining to bridge the gap between recognising these dimensions and measuring them. 

Jennifer Marino: [00:28:55] We intend to use existing Australian data to take the next steps, a conceptual audit and data analysis. The Murdoch Children's Research Institute LifeCourse initiative brings together around 30 longitudinal studies, including over 20 population-based studies involving over 40,000 participants. We plan first to undertake a conceptual audit across the cohorts of the lifeforms platform, and in the Raine study we will index key variables corresponding to the development of core competencies, capacities and strengths, defining a successful and positive transition to young adulthood, identifying questionnaire items, reflecting indicators of successful adulthood and of positive risk-taking. We'll also undertake parallel in-cohort data analyses to relate the range of risk-taking behaviours to the range of outcomes, to assess validity and robustness of the variables, to represent those intended indicators. We'll also measure associations between risk-taking behaviour, positive and negative, and indicators of success, and the contextual determinants that modify those associations. 

Jennifer Marino: [00:30:01] So to sum up, this has been essentially a little spiel about backgrounds and methods without any actual data to share with you, and our fond hope is that we will be able soon to provide you with a more complete model of risk-taking behaviour and objectively measured indicators of the consensus dimensions of successful adulthood. With the more nuanced and complete model that allows for risk-taking as a strength as well as a deficit, we can more accurately describe the transition to adulthood. Those data can be used in turn to inform interventions to nurture positive risk-taking and to empower young people and to set up health economics evaluations that will help us get a full picture of the costs and benefits of investing in the teenage decade.

Jennifer Marino: [00:31:06] Of course this work doesn't exist in a vacuum, and obviously it would be impossible without Raine study participants, their families, the Raine study team, I neglected to actually put the participants in the various LifeCourse reports on here but I should have, and I thank my Raine project collaborators as well, and my NCRI collaborators, some of whom are also Raine project collaborators. And of course, I wouldn't be here without the NHMRC or NCRIs. And having sort of bulled through this, I think I'll stop sharing my screen and give you a chance to think and ask questions and share thoughts with me, please. 

Rachel Skinner: [00:31:52] Thanks so much, Jen. That was really great, it gave us a really detailed overview of understanding risk, which we often just kind of use that term like a throwaway line when we talk about adolescence, without realising that it's actually quite a complex concept and very important for adolescents. So we do have a few questions that have come up. Sharon's asked: "Thanks, Jen, for a fantastic presentation, a new way of thinking. So how will you capture the outcomes, positive or negative? I know you've talked a little bit about it, looking at the longitudinal cohort resource through MCRI to try to identify those, but what about in the Raine cohort? What sort of scope do we have in that data linkage dataset?"

Jennifer Marino: [00:32:56] Well, I would show you the slide again, but I'm afraid that'll get us all hit by lightning, if I continue to play with the settings. But we're linking to more datasets than any cohort has been linked to in Western Australia. From the justice data we'll get justice contacts, including arrests, incarcerations, community warnings, from the hospitalisation data, obviously, we'll be able to get injury and we'll be linking to cause of death data as well. So for those very few participants who unfortunately passed away, we'll be able to determine why. We will be getting the whole range of outcomes from adverse health events to social harms, because for some of these datasets we will be linking through the whole life course to date because we're interested in hospitalisations the whole way through. Obviously, if somebody has a chronic illness, we need to think about that. If it's emerging in childhood, we need to think about that differently than we do someone who's chronic illness has just begun to emerge in adulthood. And likewise, somebody who has complications of a serious injury in infancy is different from somebody who's just had a car wreck because of reckless driving. So we've got a range of those negative outcomes. Those are the easy ones to talk about because we're all accustomed to that. 

Jennifer Marino: [00:34:32] The other consideration are those positive outcomes. I think I'm going to have to go to the LifeCourse data collection first and really give it a good think. Obviously, our thinking will be guided by the Search Institute and other consensus perspectives on this. But at some level, we're going to be working within these same domains and we're going to be saying things like, OK, if they are students did they not just progress to university, but did they excel at university? And some of that information is present in their tertiary institutions scores and the standardised tests that are available to us. It gets trickier when it comes to things like employment, but we do have data about whether people like their jobs and are enjoying their jobs, which I think is actually a fairly important and often overlooked dimension, especially in neo-liberal culture -  full employment ain't all there is to it. Satisfying employment is important as well. There are limitations, we don't know whether this person's true joy in life is going to be weaving baskets in the wilderness or playing video games competitively. We don't have that information. But in the longer term, I'd like to expand the thinking about this to include more outcomes and more possibilities. 

Rachel Skinner: [00:36:27] Thanks Jen, that was great. There's likely to be useful information that we can derive from the Raine data. There's a few other questions, one was from Lena Sanchi who's interested in health-service usage: “Will we be able to link to Medicare to get that?” 

Jennifer Marino: [00:36:49] Unfortunately, not on the current set of grants because there was a difficulty with consenting. For access to identified data, Medicare requires explicit consent for the use of those data, which is completely understandable. And when Raine participants consented, they consented to use of public databases. They weren't explicitly asked, do you agree to have us access your Medicare and Pharmacy Benefits Scheme data. So going forward, the next time that the cohort is accessed we will be asking them to consent to that. Again, contingent on funding to access it. But we are planning on looking at utilisation. We also have self report of utilisation for every follow up. So we'll be looking at that. 

Rachel Skinner: [00:37:47] We’ve got some more questions. Fiona Roberts, who I know is working on a program around raising awareness of the increasing use of e-cigarettes through the New South Wales Ministry of Health. She's asking: ”What are the implications of some of that background information you presented for strength-based messaging around risk behaviours, like e-cigarette use, which has seen a massive take up in the recent year or so in Australia in this age group.”

Jennifer Marino: [00:38:28] If it's happening with those who wouldn't otherwise have gone on to smoke, that’s a difficulty Isn't it? And if it's perceived as healthier, it's not necessarily a positive either, isn't it? I have to admit, I've never thought about that, and so I don't have an answer about strength-based messaging and Rachel, feel free to jump in if you do. Rachel's been my close collaborator on all this work. So for all I'm presenting, I mean, I'm always happy to handball a couple of these questions to her if she's better equipped. What do you think?

Rachel Skinner: [00:39:08] Well, I think it's clear that we need to look at all of the evidence around the effectiveness of strength-based interventions and strength-based communication messaging. One of the things that we had planned to do is look systematically at the evidence for effective interventions. And clearly, we would be looking at strength-based interventions as well as other types of interventions. I  think that there's a lot of scope for that. So, Fiona, we are very keen to look at that and see whether or not there is evidence that makes more of a difference. I know things like legislation and the more structural interventions tend to be highly effective, but it's whether these other dimensions are also effective. We probably don't have as much evidence for that yet. We have a question from Aija about whether all of the data is numerical or is there any interview data?  

Jennifer Marino: [00:40:24] Raine doesn't have any interview data, though I haven't started the scoping review of LifeCourse, yet, but I don't think there's probably a lot there, if any. I think there's an enormous space here and I've spent a fair amount of time mentally twiddling with how we can actually get firsthand information about how people think about risk, never mind the experimental psychology piece, but how do people think that they think about risk. But it's a tricky business to try to propose it to people because I don't know about you, but I didn't consciously start thinking this through until I was doing this work. I mean, I think that part of the sensation-seeking part and the impulsivity part is that you kind of don't think about how you take risks until you've taken them and then maybe you think of it in terms of the outcome rather than thinking of it in terms of why or how you made the decision. I think it's incredibly valuable and incredibly important to sort that out. I just don't know how we best ask the question. And particularly when you're dealing with adolescents, you need to be very skilled in how you ask questions, because they do a lot of things that they haven't necessarily articulated why they're doing them until after the fact. So I think you have to have a very skilled interviewer and you have to put some really serious thought into how you frame the questions. But I would be happy if it turns out I'm wrong, if somebody does have interview data about this, please come tell me. I'd be excited to know about it. 

Rachel Skinner: [00:42:14] "Hi, Kate Steinbeck here Jen, great presentation. We really need these important studies in order to shift the stereotype of adolescents being big risks to themselves and others. How can we start to change the conversation?" 

Jennifer Marino: [00:42:30] I'm trying and I'm happy to go out there and continue to say, well, OK, let's not think of it entirely in negative terms.  As academics, we have all these options, like publishing articles in The Conversation, doing outreach and translation. But there's also thinking about it starting at home. You know, everyone who has teenagers kicking around the house, talking to them about how they think about it. I know that all parents of adolescents pretty much think all the time about, 'how am I parenting and am I actually destroying my child in some way?’. So turning that worry to something constructive, like a conversation with your kids seems like a good place to start. And with all of the tremendous connections between WH&Y and education and the Centre for Adolescent Health and MCRI and education, I think there's lots of ways to touch the lives of young people and say, you know, we respect you and we respect your decision making more than maybe the discourse suggests. Can you talk to me about how you want to do this? I think the WH&Y Youth Commission is probably also a really great place to start. So those are some thoughts. But again, anybody who has anything come to me and I'm happy to hear it. 

Rachel Skinner: [00:44:01] And it's really good to mention the Youth Commission because they do play a really important role in helping us translate the sorts of findings that we have out into the world of young people. 

Jennifer Marino: [00:44:15] And actually, this past weekend, we did a research method speed dating that Pip Collin set up for us and her crew with WH&Y Youth Commission. And one of the Commissioners pointed out to me that our model is very linear. It doesn't take into account the fact that behaviours and outcomes feedback into decision making. And that was really significant food for thought for me. And every one of the group pretty much raised either the word intersectionality or the concept of intersectionality and the notion that we need to be very aware of the fact that disadvantage and advantage are multiaxial and intersect and that we need to undertake these analyses with acute awareness of context. And I thought that was a really useful insight.

Rachel Skinner: [00:45:20] We didn't imagine how interested and of value they would be to a birth cohort, but it was really wonderful to get their input. So Annabel Hobbs says: "Thanks, Jen. I was just interested in the concept of positive risk-taking if the bad outcomes are deemed mild, considering the differences in how people perceive the severity of outcomes, did the authors comment on any examples of positive risk-taking that are beneficial in adolescence?”

Jennifer Marino: [00:45:54] Yes, and there's even a couple of instruments to measure them, and they're all influenced by the perceptions of the people designing them, as all instruments are. What I'm trying to say is that they're not coming out of the sort of standard instrument validation concept. But to answer the question, some examples are performance, like on stage, social risk, if you're in a group. I mean, some of the items that are asked are things like, if you're in a group of your friends and someone says something or does something that you're very uncomfortable with, do you say anything or do you do anything? Imagine that you were trying out for a play? Would you do that? So they're trying to frame it in terms of the potential outcome. Is all that happens if you try out for and you don't succeed, is you're embarrassed, you haven't broken the law, you're not going to go to prison, you're not going to break your leg. So the potential cost is actually fairly low. But in the adolescent context, embarrassment is actually a pretty high cost. So you have to consider this stuff from their perspective. In addition to that, there's sport, there's physical risk-taking, and again, we're not necessarily talking about climbing on a fence or climbing up on the roof. We're talking about do you try out for a sports team? So there's a lot of examples that are being used, but we're still in the very early days of thinking about it. And there's no consistent consensus about what it really is.

Rachel Skinner: [00:47:53] Another really important question, which also came up on Saturday with our Youth Commission, is about the diversity within the cohort and particularly the question of what proportion of the participants identify as Aboriginal or Torres Strait Islander. And we also had the question from our Youth Commissioners about the cohort itself, which clearly from that picture looks very dated. They were born in Perth. And so what are the implications? And they were all the same individuals that have been followed through time. So what are the implications of that? The specific cohort that we're looking at compared to Australia today, young people today, is likely to be quite different. 

Jennifer Marino: [00:48:46] Succinctly, yes - 1989 Perth was not a hotbed of diversity and for all that 1989 Perth did have a fairly substantial Aboriginal and Torres Strait Islander population, that doesn't mean that they were necessarily captured in the birth cohort. So definitely indigenous people are under-represented in the cohort. And one of the plans that I didn't talk about is to go on and develop this work Growing up in Australia, a Longitudinal Study of Australian Children, and the launching of the Juvenile Study of Indigenous Children, and some certain other cohorts to which we have access that will provide a very different and more diverse perspective. But we've got to start somewhere, and this is the cohort that we've got the most experience with, but we're very much aware that this is all going to be extremely culturally bound. 

Rachel Skinner: [00:49:53] We have one final question from Corinne: "A great presentation with a lot to think about. But there is a lot of peer learning and self learning through social media among adolescents. Could this be used to engage adolescents in the discussion, using adolescent leaders, for example, leading these conversations, designing media perhaps for interventions?" 

Jennifer Marino: [00:50:32] For sure, things like taking it to The Conversation I think that's actually a really solid idea. I'm mindful of the fact that some of the most effective communication around the experience of being a trans young person has been coming from trans young people themselves in Australia. And I think that's a really good model for how we can engage, because some of these young folks I've met at conferences, I've seen their work in The Conversation, I've seen them on the TV, on shows that are not on public broadcasting. And so I know that anything I can say 50 times as a middle-aged academic would be much more effectively communicated to both adolescents and their parents by an adolescent, by an articulate, smart, well briefed, thoughtful adolescent. And so I think that's a really valid observation. And we do have folks in WH&Y who are co-designing work and who are developing work that way. And I hope that I can learn from them and we can do the translation that way. 

Rachel Skinner: [00:52:05] We also conducted a study on social media and how that influences young people's perceptions around sexual activity, sexual behaviours and relationships and how it can support agency in young people of very diverse sexualities and genders as well. We are doing separate work, but the Raine cohort doesn't lend itself very well to this type of work because we've basically got what we have. They're all for different purposes, but we can cross fertilise our different research projects with the learnings that we take away from the various things, and that's the beauty of WH&Y because we have such an interdisciplinary group of researchers, social science researchers, health literacy researchers, population health and epidemiology researchers, and young people, of course, and clinician researchers. We can draw on all of our strengths to try to answer what are complex and complicated questions around youth health. So thank you to everybody for your attendance and your participation. And thanks, Jen, for a wonderful presentation. You did really well. 

Jennifer Marino: [00:53:40] Thank you so much for the opportunity. And I think the question session alone was worth the price of admission. So grateful to all of you for sharing your thoughts. And I really appreciate you being here. 

Rachel Skinner: [00:53:56] Excellent. Thanks, Jen. See you all next time.