Adolescents as Deliberative Citizens: Building Health Competence in Local Communities Mary Carlson and Felton Earls Harvard University Abstract Given the host of tragic events that children experience, it is often compelling for well-intended adults to respond in a protective and charitable fashion. The child rights approach asks for more. Building on our collective experiences in the developmental and social sciences, we present in roughly chronological fashion a synopsis of the theoretical explorations and scientific evaluation that completes a framework to advance the status of children as citizens. Fundamental to this project is the recognition of the agency and capability of the child and the dynamic and enduring source of socialization from and social integration within the community. The participatory rights enshrined in the Convention on the Rights of the Child serve as an impetus and inspiration to this project, the Young Citizens Program. What began with small-scale deliberative groups in Chicago matured into a cluster randomized controlled trial in northern Tanzania. Authors Mary Carlson is Associate Professor of Psychiatry at Harvard Medical School and Children’s Hospital Boston. In 1991, a major career transition from developmental neurobiology to social policy was facilitated by study at the Harvard Kennedy School and with Amartya Sen around his Capability Approach. Her new research focuses on early child deprivation (and enrichment) and the development of methods to enable deliberative citizenship in adolescents to promote health and well being of their communities. Felton Earls is Professor of Human Behavior and Development at the Harvard School of Public Health and Professor of Social Medicine at Harvard Medical School. From 1990 to 2005, he was the principal investigator of the Project on Human Development in Chicago Neighborhoods. His current project, Ecology of HIV/AIDS and Child Mental Health in Tanzania, is a cluster randomized control trial which aims to strengthen adolescents’ capacity to promote community health. While the condition of children in Africa is rife with examples of widespread tragedy, there are many reasons for optimism. The present HIV/AIDS epidemic, disproportionately affecting sub-Saharan Africa, has led to the popular characterization of children in this region as “orphans and vulnerable”. The labeling of children by their circumstances rather than their capacities is unfortunate and stigmatizing (Earls, Raviola and Carlson, 2008). It is an orientation that invites charity rather than respect. Every energetic, knowledgeable and joyful child represents the hope of a more positive future -- an Africa that is socially and politically vibrant, economically developed, and equitable. Children cannot thrive if their communities are not capable of providing consistent, responsive and competent care, along with good governance and human services. Nor can communities prosper if the youngest members are not recognized as respected and active participants. Such a hopeful attitude for Africa and her children applies to all children and settings, as envisioned by the United Nations (UN) Convention on the Rights of the Child (CRC). This remarkable document inspires our view that children be recognized as "young citizens". 2 The first half of the paper characterizes the theoretical formulation and research that establishes our perspective on children as citizens. From a theoretical foundation informed by Amartya Sen and Jürgen Habermas among others, we developed the Young Citizens Program (YC Program). The second half presents the evolution of the Program from a small scale series of deliberative groups in Chicago and Cambridge to its rigorous evaluation in a community-based randomized control trial in Tanzania. The objectives of the Tanzanian study are to measure the consequences of children’s participation in actions to promote community competence. The adequacy of our evolving theory is judged by how well it addresses children of different ages and across a range of advantaged to disadvantaged environments. The legitimacy of this approach requires the perspectives of children themselves and must be judged by the ethical and practical implications such formulations have for children’s current well being and extended life course. Children and Deliberative Citizenship: A Theoretical and Pragmatic Framework The status of children as citizens to genuinely participate in the community requires the recognition and guidance of adult citizens. In a thought-provoking essay, Children: Noble Causes or Worthy Citizens, Swedish social scientist Karl-Eric Knutsson argues that we must move beyond the charitable approaches of “Noble Causes” to the post-CRC vision of “Worthy Citizens”. In his concluding chapter, “Recognizing the child citizen” he states ” In order to lay a basis for finally recognizing the child as citizen we must consider the larger contexts of globalization and intergenerational perspectives as well as more immediate political environments on the national and local levels. We must also consider the need for new partnerships for children and with children based on the conviction that the best interest of the child is in most cases also the best interest of the larger society (Knutsson, 1997, p.123). His reflective and critical thesis builds on a practical understanding gained 3 through several significant positions held with UNICEF. His experiences provide the ideal blending of scholarship and practice and a source of confirmation that academics can contribute to the behavioral and social foundations necessary to give direction and validity to the many CRC articles. He brings the clarity, skepticism and depth of a veteran social scientist to this controversial and demanding tension between the participation and protection rights. To take into consideration the multiple contexts that frame both the protection and participation domains requires looking beyond conventional medical, public health and neurobehavioral disciplines for new theoretical constructs to guide measurement and analysis. The synthesis, application and evaluation required of biological, behavioral, and social factors and their interactions with political and material resources for children at different ages across their life courses is daunting. Our project to determine the interests and competencies of children, along with the required support and guidance of adults, is framed in a public health schema. The intent is to evaluate this program with a rigorous experimental design. The revolutionary new status of children as “rights holders” endows them with respect, equality, legal guarantees of protection by state and non-state actors, as well as their recognition as social agents. The bold and expansive CRC document transforms the basis of policy analysis and formulation from simply the "developmental sciences" to include political philosophy and social science to address issues such as identity/membership, equity, authority, legitimacy, obligations and social justice. In the search for social theories that bolster the conceptual framework for our project, five major features are required to meet the high standards of the CRC. Firstly, the presumption of universality is a distinguishing feature of the CRC. Secondly, the theory must incorporate agency as a fundamental 4 characteristic of the child as a rights holder. Thirdly, the theory must be equity sensitive to compare individuals and groups with regard to resources and opportunity disparities. As a fourth element it is important to address governance as an integral aspect of its scope since it is governments that ratify the CRC, enact legislation, and enforce the rule of law. Finally, it must be emphasized that the CRC is concerned with adverse issues such as abuse, exploitation, deprivation and conflict yet routinely addresses children in a positive framework of rights promotion, disease prevention, conflict resolution and social progress. Public and social choice theories have a long political history through the analysis of voting and other forms of social preference. Kenneth Arrow’s penetrating analysis of the “impossibility of rationally deriving social choice from individual preferences” has led to major rethinking of social preferences in the political realm (Sen, 1999). Amartya Sen, an economist and social philosopher, responds to the challenges posed by the Impossibility Theorem by exploring new informational spaces where coherent interpersonal assessment of valued outcomes is possible. Sen’s pioneering work on the Capability Approach provides an alternative model for situating social agents and evaluating distributional properties of their well-being. Rather than a model in which well-being equity is based on mental states (such as preferences or utilities) or as resources (such as commodities or primary goods), he proposes that one measures human “functionings”-- defined as the various things a person may value doing or being (Sen 1985, 1993). A second parameter is “capability sets”, defined as a space in which a person is free to choose among alternative bundles of functionings. In more common parlance, sets are valued lifestyles from which a person can choose, based on their personal characteristics and the availability of opportunities and resources (Sen, 1992). A third important distinction is between functionings (valued by a person) and capability sets (bundles of available alternative functionings), and “achieved functionings” -- characterized by what a person actually 5 chooses, does or becomes. Achieved functionings can be observed, measured and assessed as constituent features of a person. Lastly, “capability” can be understood as a substantive freedom to achieve alternative sets of functionings and does not require that a choice is actually exercised (Sen, 1992, 1993). Capability and its components operate in a distinct, multidimensional informational space, less restricted than the social choice/voting space addressed by Arrow’s theorem. Capability, as freedom, is seen as having both an intrinsic as well as instrumental value (1992, 1999). This remarkable theory with its origins in welfare economics and social philosophy meets all the criteria by which we frame our research on child citizenship. Sen aims for capability theory to have universal application, as he intentionally under-specifies functionings except to say they range from simple to complex and vital to trivial. Human agency is foundational to capability and equity issues are crucial to interpersonal comparisons. Capabilities are envisioned as positive and optimistic states of being without ignoring the causes and consequences of capability deprivations. In discussing possible functionings Sen often refers to the political freedom to participate in public life. The applications of Sen’s theories to children are summarized in his Development as Freedom volume (1999). In his most recent and ambitious work, The Idea of Justice, he begins with a quote from Dickens’ Great Expectations, “In the little world in which children have their existence, there is nothing so finely perceived and finely felt, as injustice”. Through this quote Sen acknowledges that capability and well-being begin in childhood and that justice is a remedial concept (Sen, 2009). Our first application of the capability theory was proposed as an alternative approach to inform programs on early crime prevention (Earls and Carlson, 1995) . Building on our research on early brain and behavioral development, we proposed that capability added an important new perspective of 6 children as agents. It allowed one to measure their socioeconomic contexts as either constraining or expanding their capability sets at different ages. “Choice” is not a sufficient parameter by which to measure a child’s engagement with their available capability sets, because many of children’s key functionings are social, such as intimacy, language, and play. A parameter that captures the shared exchange between a child and caregiver is needed to explain the reciprocal interaction necessary to achieve functionings, and is critical in early development. Our growing interest in deliberative democracy as a context for children's competencies as citizens led us to look for complementary models that could adequately incorporate reciprocity. Unlike electoral citizenship, deliberative citizens can be recognized at any age they are ready to engage in rational discourse. Whereas electoral citizenship simply aggregates preferences, deliberative democracy provides for a public exchange of information, perspectives and reasons. It is a process designed to achieve consensus among all individuals affected by an explicit publicly-generated decision. In exploring the types of functionings required for children’s participation in deliberative activities, we are influenced by the extensive writings of. Jürgen Habermas. Habermas’s The Structural Transformation of the Public Sphere presents a two-level concept of society (1991, published in German in 1962). The public sphere is where people assemble and are free to engage in discourse about common societal problems. Along with the private sphere, it represents networks of communication and sources of socialization and social integration and together is what he refers to as “lifeworld”. He distinguishes the lifeworld from the media-steered system composed of the corporate/economic and state/administrative subsystems that operate through purposive-rational action in pursuit of money and power. His view that citizens have been transformed to spectators by the media rather than actively engaged in public discourse is a major concern. He concludes this 7 treatise by suggesting that one study the extent and manner by which the pubic sphere can be rehabilitated. In his subsequent two-volume major work, The Theory of Communicative Action (1984, 1987, published in German in 1981), he fully develops his optimistic claim that this function can be restored and posits language (defined as speech acts) as “a medium for reaching understanding and language as a medium for coordinating action and socializing individuals” (1987, p.23). His scholarship expands notions of citizenship by placing emphasis on democratic procedures that value reason and an open exchange of ideas as a basis of legitimate governance. He asserts that consensus achieved in the lifeworld through communicative practices must be based on reasons and intersubjective recognition of validity claims. In taking a discursive and rational approach to justification, he distinguishes three dimensions of validity claims and associated modes of communication: 1) Truth, as the objective world of existing affairs; 2) Rightness, as the normative context that provides legitimacy; and 3) Truthfulness, as subjective intent of expression and privileged access to lived experience. Yet, he cautions that ”Communicative action relies on the cooperative process of interpretation in which participants relate simultaneously to something in the objective, the social, and the subjective worlds, even when they thematically stress only one of the three components in their utterances.” (Habermas, 1987, p.120). He distinguishes between the social and objective domains of the external world and describes how individuals use language to share experiences of the their subjective lifeworlds, in the process of seeking mutual understanding in pursuit of action goals in the external world. In his critique of modernization he cautions that the “progressively rationalized lifeworld” becomes “both uncoupled from and made dependent upon increasingly complex, organized domains of action” (Habermas, 1987, p. 305). 8 Following on these same themes in Moral Consciousness and Communicative Action (Habermas, 1990, published in German in 1983), he proposes “discourse ethics” as a further elaboration to establish the normative validity of rational argumentation as a basis for moral insights. In doing so, he posits that equal attention and weight should be given to the individual and the community. He states: “They must emphasize the inviolability of the individual by postulating equal respect for the dignity of each individual. But they must also protect the web of the intersubjective relations of mutual recognition by which these individuals survive as members of the community. To these two complementary aspects correspond the principles of justice and solidarity, respectively. The first postulates equal respect and equal rights for the individual, whereas the second postulates empathy and concern for the well being of one’s neighbors.” (Habermas, 1990, p. 200). Discourse ethics, as an elaboration on the earlier deliberative procedures of communicative action was especially interesting to us as a method to engage families and communities around the perspectives of researchers and participants in our on-going research with children For several years, starting in 1996, we employed discourse ethics to engage families, community social service agencies and adolescents in extended deliberations on our social and biological research with infants, young children, and adolescents. This work was made possible with initial support from the National Science Foundation1 (Carlson and Earls, 1997; Earls and Carlson, 2002). Beginning with the practical translation and application of communicative action and discourse ethics, we combined capability model with communicative competencies in a diagram of the developmental components of deliberative capabilities (Earls and Carlson, 2002). In a later section we present a revised version of that earlier diagram illustrating the measures of the components of achieved deliberative functionings. 9 Habermas’ scholarship is in keeping with our criteria for selecting theoretical models as he strives for principles of universality and equity in public discourse. In spite of his penetrating critical appraisal of past and current social theory, he appears unwavering in his optimistic view of what is possible. His work is a statement of hope about better governance. We have labored to extract what would appear to be basic elements of communicative competency that we could target in children and adolescents to support and enhance their potential for communicative action. Four practical components that are opertionalized from this work are: 1) Mutual trust as normative accord, sincerity. 2) Perspective- taking as the ability to take the attitude of the other in practical discourse; 3) Mutual understanding as achieved through symmetrical communication; and 4) Shared social action through which a situation and a theme is identified and consensual understanding and action plans are realized. These components are discussed below in the description of the modules used in the Young Citizens Program in Tanzania along with the measures of individual elements of deliberative capability. In addition to the foundational theories of Sen and Habermas, we have drawn on the work of three other scholars to complete our theoretical formulation for child citizenship. Bandura’s work (1986) on social cognition is concerned with personal judgments of how well one can execute courses of action required to deal with intended outcomes. His close attention to measuring self-efficacy constructs in specific situations and with specific functions in mind is a tremendous advantage to our empirical orientation. It helps to link notions capability and deliberation by creating new measures termed deliberative and communicative efficacy. These constitute competencies that are at the core of what it means to be a citizen. 10