Transcript Effects of Personality Risk Education on Substance Use and

Preventing adolescent alcohol
and drug use:
Indicated programs
Clare J. Mackie, Ph.D.
Lecturer
Addictions Department
Institute of Psychiatry, KCL
Learning outcomes
After attending this lecture students
should be able to:
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Outline the major aims of an indicated prevention
program
Provide examples of indicated prevention programs
and outline the methods used within each program
Describe the factors that contribute to the efficacy
and effectiveness of indicated prevention programs
Discuss whether different prevention approaches
can be combined to prevent adolescent substance
use
Lecture 1: Indicated
Plan
1.
Description of indicated programs
2.
Types of indicated prevention programs
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3.
Motivational or brief intervention
Family
School-based
Peers
Summary and Conclusions
1. Intervention strategies
Universal Prevention
Selective
Likelihood of
developing problems
Indicated
Early Intervention
TREATMENT
1. Indicated programs
Indicated prevention programs serve individuals with
signs or symptoms of substance use, but are not
meeting DSM criteria for dependence.
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However, this particular field is often neglected as individuals
may also be in treatment.
Demanding to deliver
– Combine individual and small group delivery
– Examining a particular behaviour or need
– Trained therapists
Very costly as often needs to be individualised.
Nevertheless indicated programs are critical in terms
of continuum of care. Can offer the highest probability
of getting services to those who experience the
greatest individual harm.
1. Indicated programs
The aim of the intervention is to prevent progression
to DSM disorder
– Should target transition to dependence and associated
harms rather than onset or use
– Indictors should correlate with substance use more
strongly than those used in selective interventions
– Family, peer or community indicators are not suitable,
individual indicators should feature more prominently.
(Springer & Philips, 2007)
1. Indicated programs
Defining the indicated participant criteria
 Similar to selective programs, indicated programs
are defined by the participant characteristics
– Selective is defined by shared characteristics, indicated
more by individual characteristics
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Population characteristics are complicated by
– Explicit definition of types of criteria
– Nature and strength of the criteria to substance use –this
will be stronger for indicated than selective prevention
programs
– Implies a need for a screening instrument
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Additional risk criteria is also used e.g. school
failure, mental health problems
1. Indicated programs
Participant recruitment and access to indicated
services
 Individualised screening process to identify those
individuals in need of focused and intensive
interventions to prevent progression to dependence
 Three avenues of recruitment
– Self-referral (individuals maybe experiencing negative
personal consequences)
– Teachers, counsellors, parents, peers
– Automatic referrals from A&E departments, police for
substance use possession
1. Indicated programs
Participant recruitment and access to indicated
services
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Indicated populations can be defined
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narrowly by based on a single criteria (e.g. patterns of SUD)
A narrowly focused cluster of indicators (e.g. behavioural)
Broader set of indicators such as school failure
The decision regarding how widely to screen has implications
for service delivery
Multi-problem screening may take place where prevalence is
low and multiple issues are of a high concern e.g. schools
Where the population is larger and problem more specific (e.g.
workplace), more focused criteria is appropriate
1. Indicated programs
Designing and selecting indicated services and
approaches
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In contrast to universal and selective there are few
models for indicated programs
Mix between group facilitated sessions involving
peers and individual sessions
– Group sessions include skills development, discussion and
support groups
– Individual sessions are provided by counsellors or
therapists
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Supporting individuals with multiple problems
1. Indicated programs
Specifying appropriate outcomes
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Outcomes should differ from universal and
selective programs
– Include reduction of substance use, in particular
harmful use e.g. binge drinking
– Serious or co-occuring problems –an important
aim of indicated programs is to prevent
progression of negative behaviours
1. Indicated programs
Summary
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Indicated programs are the last stop for
prevention services for individuals who are
close to needing treatment
Indicated programs are a neglected
component of prevention
Might be less useful for school or LEA’s
Main barrier to implementation is the cost
and can be extensive to deliver
2. Types of indicated programs
Motivational or brief intervention
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MI seeks to promote reflection on drug use and its
personal consequences in the context of the values
and goals of the individual.
Considered that older adolescents and young adults
may benefit from MI as non confrontational and
does not impose specific outcomes
There is a large literature on motivational
interviewing, but few studies with early problematic
substance use with adolescents
2. Types of indicated programs
Motivational or brief intervention
McCambridge and Strang (2004)
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179 16-20yrs who had current involvement with
illegal drugs
Weekly cannabis use or stimulant drug use in the
previous 3 months
Recruited from FE colleges by peers. College staff
identified students who were willing to recruit peers
to the project.
– Peers were then trained in recruitment and interview
techniques.
McCambridge and Strang (2004)
Intervention
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Initial interview lasting 60 minutes involving a
discussion of the range of drugs used
Afterwards the interviewer discussed the particular
areas of risk or concern
The objective was to create an opportunity for the
participant to think and talk about risk in a way
conductive to illicit change
– To stimulate new ways of thinking about drug use
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The control condition was education as normal
3month follow-up (FU)
McCambridge and Strang (2004)
Outcome measures
 Severity of Dependence Scale
– Drug use dependence
– Consumption
 Drug related harm
– Health-related e.g. GP visits
 Interactional risk
– Drug selling, intoxicated arrests
 Motivation to change
 Attitudes to drug use
Changes in drug use consumption
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16
14
12
10
8
Intervention
6
Control
4
2
0
Alcohol units Alcohol units Cannabis
-Baseline
-FU
(Freq)
Baseline
Cannabis
(Freq) FU
Changes in drug use consumption
45
40
35
30
25
Intervention
20
Control
15
10
5
0
Cigarette (Freq) Baseline
Cigarette (Freq) FU
Changes in drug specific attitudes
Intervention group:
– more likely to have made a decision to
reduce smoking, alcohol and cannabis
use
– Less likely to view smoking and alcohol
use as important to them
– Fewer participants reported interactional
drug use problems
Conclusions and implications
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Young people can benefit from MI as longterm adult users
Reduction is of benefit as stopping all
together
Benefit found across different drugs
Benefit of risky drug use behaviours
Shift in perceptions of drug use
– However, no longer term benefits at 12
months (McCambridge and Strang 2005)
– Use of educational only control
2. Types of indicated programs
Motivational or brief intervention
Marsden et al (2006)
Brief motivational intervention to induces positive change with
young regular ecstasy and cocaine users.
 342 (16-22 years) participants self-identified.
 RCT –intervention V’s Control – 6mth FU
Intervention
 45-60 minute manual-based discussion around 8 topics.
– E.g. discussion about activities surrounding drug use,
perceptions of ‘good’, ‘bad’ use, views for behaviour change.
– Control group –information only
 Delivered by youth workers and researchers with experience of
youth drug work and training in MI.
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2. Types of indicated programs
Motivational or brief intervention
Outcome measures
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Maudsley Addiction Profile
– Prevalence of cocaine, cannabis and ecstasy use
– Frequency of use
– Quantity of use
Severity of Dependence Scale
– Extent of problematic use
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AUDIT
– Hazardous drinking in previous 90 days
Intervention effects-Ecstasy
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12
10
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6
4
2
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Intervention
Control
Frequency
(days)
Baseline
Frequency
(days) FU
Quantity
Baseline
Quantity FU
Intervention effects –cocaine
10
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2
1
0
Intervention
Control
Frequency
(days)
Baseline
Frequency
(days) FU
Quantity
(Grams)
Baseline
Quantity
(Grams) FU
2. Types of indicated programs
Motivational or brief intervention
Results
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No significant difference between intervention/
control at 6mth FU
Both groups reduced their stimulant use
59% of the intervention group and 41% of the
control group reported an attempt to reduce or stop
stimulant use.
– 78% of the intervention group reported that the
intervention had prompted them to change their
behaviour.
– 87% of the control group.
2. Types of indicated programs
Motivational or brief intervention
Conclusions
 The intervention was no more effective at
inducing abstinence than and reducing
stimulant use than information only control
condition.
 6mth FU may too late to detect results
 For a young sample, focusing attention on
drug use may be sufficient.
2. Examples of indicated programs
Family Centred
Large literature on family-centred programs
 E.g. Strengthening families prevention program
(Kumpfer & Turner, 1991)
– Initially developed as an indicated prevention program for
high-risk families, parents who are current drug users
– Adapted for high risk children with risk factors such as
problematic or delinquent behaviour
– premise that poor parenting was responsible for the
increase in adolescent alcohol and drug use.
2. Examples of indicated programs
Family Centred
The objective of family-based prevention programs
should be to decrease risk factors while increasing ongoing protective mechanisms
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5 major types of protective family factors:
– Supportive parent-child relationships
– Positive discipline methods
– Monitoring and supervision
– Family advocacy for the children
– Seeking information and support for the benefit of the
child
Bry et al (1998)
2. Examples of indicated programs
Family Centred
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Behavioural parent training
– Highly structured approach over 12 1-2
hour sessions
‘Good’ ‘bad’ parenting models
 Interactive exercises
 Role playing of parenting behaviour to be
changed
 Improve parent-child relationships, rewarding
good behaviour and ignoring negative
behaviour.
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2. Examples of indicated programs
Family Centred
Barriers to implementation
 Access to high-risk families, difficulties with
recruitment and maintaining program
 Program is intensive and need continuous
attendance for successful results
 Separate parent and child sessions, parent with
child sessions
– Although, very successful in reduction of alcohol and drug
use (cochrane reviews)
– Implemented as SPF 10-14 universal program, adapted in
the UK (Foxcroft)
2. Examples of indicated programs
School or community focused
School-based strategies to motivate and provide
social support from specific adults in the high risk
individuals social network.
– Setting norms for and monitoring use of alcohol, tobacco,
drug use at school.
– Improving the overall school network support.
– Facilitating prosocial school bonding.
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Social network support should
– Directly increase students’ personal competencies and
control, reinforcing a positive view of teachers
– Directly increase conventional school belonging through a
sense of purpose
2. Examples of indicated programs
Peer-focused
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Peers represent a critical content for delivering
prevention strategies for high-risk youth and the
key strategies are to develop a positive peer-group
culture.
– Setting and maintaining norms –making personal
commitments for decreasing drug/alcohol involvements
– Adopting and reinforcing daily the norms of a positive peer
group culture
– Replacing deviant group bonding with pro-social group
bonding
Summary and conclusions
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Indicated prevention describes a preventative
individualised approach targeted at individuals at
high risk of developing SUD
The need for an indicated approach is the presence
of indicators for the development of later (not at
presence) SUD
– Aim of the approach is to prevent a progression to
dependence
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Current prevention programs tend to utilise brief
interventions such as MI or parent training
program.
– Most try to reach adolescents with elevated drug use
– Families with high risk behaviour
Summary and conclusions
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However, costly to administer
Co-operation between different
agencies e.g. schools and therapists
– Family interventions are time-consuming
and result in difficulties in recruitment
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Overlap between selective programs
and early treatment.