Transcript The state of drug prevention in the European Union

The state of drug prevention in the
European Union – connecting to
Families
Gregor Burkhart - Porto – 19 November 2007, 10:00 – 11:30
The EMCDDA
• EU information collection centre
on drugs and related problems
• Collection, analysis and
distribution of ...
• ...“objective, reliable and
comparable” information
• Annual Report on the
state of the drugs problem
in the European Union, Turkey and
Norway (in 25 languages)
• Specific reports on specific
aspects
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Based in Lisbon - Portugal
Outline
• Family involvement in school-based
prevention
• Universal Family-based prevention
• Selective family-based prevention
• Deprived neighourhoods and ethnicity
• Indicated family-based prevention
• Family aspects in mass media campaigns
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Family involvement in school settings:
Expert ratings
Quantitative data
(structured questionnaires)
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Events for parents in school-based
prevention – SQ 25
No response
No Information
Interventions seldom or not
available
Interventions sporadically found
Interventions regularly available
Interventions very common
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N° of sessions offered to parents per school year within
standardised school-based prevention programmes
80
n=187
Mean n° sessions: 10
Median: 3
70
2004 data
11 member states
33% offer sessions at all
60
ST- 19
(61 / 187)
50
40
N° of sessions
offered to
parents per
school year
30
20
10
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SP
SP
SP
PT
NO
NO
NL
IT
IT
IE
HU
GR
GR
GR
GR
GR
GR
GR
GR
GR
GR
GR
GR
DE
CZ
BeFr
BeFl
0
Universal family-based prevention in
community settings
expert ratings
(structured questionnaires)
and EDDRA
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Family or parents meetings
and evenings
No response
Not known
Seldom or not available
Sporadically found
Regularly available
Very common
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Trainings for family
No response
Not known
Seldom or not available
Sporadically found
Regularly available
Very common
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Family to family peer
approaches
No response
Not known
Seldom or not available
Sporadically found
Regularly available
Very common
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Actividades desarrolladas
2
Contents of family-based
prevention
programmes in EDDRA entries
3
Short t erm t reat ment
9
Treat ment
13
Communit y work
9
Family t herapy
9
Theat re
5
Workshops
6
Comunit y services
10
Seminars
31
Parent s meet ings
2
CDs
9
Proximit y int ervent ion
6
Crisis int ervent ion
5
Low t hreshold services
30
Inf ormat ion
4
4
Grupos de presión
Fiest as
0
5
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10
15
20
25
30
Universal prevention
• In pre-teenagers, family influence prevails over peer
influence
• The role of the family in establishing norms and
support for children is more relevant to prevention
than imparting information on substances
• But information provision is very frequent in reality
• Increasing (DE, ES, IE, IT, UK) acknowledgment of
difficulty to contact problem families
• UK: FRANK campaign has developed an action pack
on how to reach the family
• Universal prevention offers tend to pre-select the
well-off parents
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Selective prevention
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The prevention “filters”: intervention criteria
Universal prevention
no filter
Filter I: social, demographic predictors
(no prediction on individual risk)
Filter II: expert-diagnosed risk
factors: individual mental
health or conduct problems;
drug use not obligatory
Selective prevention
“Filter“: drug
use alone
as predictor
Indicated prevention
Early intervention
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Background for risk-factor approaches
% Comparison of lifetime any drug use by groups
aged 12-16
(Source: UK Youth Lifestyles Survey 1998/1999)
60
50
40
30
20
10
0
Young people with older School excludees and
sibling who used any
truants
drug last year
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General population
Universal family interventions versus targeted interventions for families
at risk in drug prevention policies (not social policies)
Importance in drug policies (%)
Universal
120
100
80
60
40
20
Rate selective family-based
Rate universal family-based
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bo
ur
g
Lu
xe
m
Fr
an
ce
Ne
th
er
la
nd
s
Ro
m
an
ia
Cy
pr
us
h
fle
m
is
ly
Ita
Be
lg
iu
m
y
Hu
ng
ar
a
Au
st
ri
G
re
ec
e
Po
rtu
ga
l
0
Universal family interventions versus targeted interventions for families at risk in
drug prevention policies (not social policies)
Importance of implemented interventions (%)
120
Universal
100
80
60
40
20
um
lg
i
Be
Rate universal family-based
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nc
es
fra
la
nd
et
he
r
N
bo
ur
m
Lu
xe
um
lg
i
Be
Rate selective family-based
s
g
e
nc
Fr
a
s
yp
ru
C
om
fle
m
is
an
h
ia
It a
ly
R
H
un
g
ar
y
e
ec
G
re
st
ria
Au
Po
rtu
ga
l
0
Substance abuse in family
?
No response
+
-
Not known
!
Seldom or not available
Not known
!
Priority in written drug
policies
+
Mentioned in written
drug policies
-
Not explicitly mentioned
in written drug policies
Importance at policy level
Sporadically found
+
Regularly available
+
-
Very common
+
+
!
+
-
-
!
+
-
+
-
+
!
+
+
+
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-
Socially disadvantaged parents
(e.g. unemployed)
?
No response
!
Not known
-
-
Seldom or not available
Not known
!
Priority in written drug
policies
+
Mentioned in written
drug policies
-
Not explicitly mentioned
in written drug policies
Importance at policy level
Sporadically found
-
Regularly available
+
-
Very common
+
-
-
-
-
?
+ +
-
!
+
+
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+
-
Family conflict and neglect
?
No response
-
Not known
+
-
Seldom or not available
Not known
!
Priority in written drug
policies
+
Mentioned in written
drug policies
-
Not explicitly mentioned
in written drug policies
Importance at policy level
Sporadically found
-
Regularly available
+
-
Very common
-
-
-
+
-
-
-
?
+ +
-
!
+
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?
-
Criminal justice problems
in family
?
No response
-
-
Not known
Not known
!
Priority in written drug
policies
+
Mentioned in written
drug policies
-
Not explicitly mentioned
in written drug policies
Importance at policy level
Seldom or not available
Sporadically found
Regularly available
-
!
Very common
-
-
+
-
-
?
+ -
-
-
+
?
!
+
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?
-
Families with mental health
problems
?
No response
-
!
Not known
Not known
!
Priority in written drug
policies
+
Mentioned in written
drug policies
-
Not explicitly mentioned
in written drug policies
Importance at policy level
Seldom or not available
Sporadically found
Regularly available
+
!
Very common
-
-
-
-
-
-
-
?
- -
-
-
!
+
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?
-
Ethnic families in marginalisation
?
Not known
No response
!
Priority in written drug
policies
Not known
+
Mentioned in written
drug policies
-
Not explicitly mentioned
in written drug policies
-
-
Seldom or not available
Importance at policy level
Sporadically found
Regularly available
+
Very common
+
-
-
?
-
?
-
+
-
?
?
- -
+
-
!
+
+
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?
-
Vulnerable families – National Reports
• New Member States (Bulgaria, Hungary, Lithuania,
Poland and Romania) report much on interventions
aimed at vulnerable families
• The focus is on substance use in the family; only BE,
DE, AT are focusing increasingly on children of
alcoholics
• Few countries (Greece, Lithuania, Hungary, the United
Kingdom) have adopted a broader focus aimed at all
socially disadvantaged families.
• Programmes for neglected children and young people
from dysfunctional families are being run in Poland and
in some provinces in Austria.
• implemented in local community-based venues such as sociotherapeutic common rooms, upbringing facilities, youth clubs and
prevention centres.
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Strengthening Families Programme (K. Kumpfer)
• For families with low SES and/or ethnic background
with kids 11-14 years at risk
• Intensive: 2-3 h/w during 14 weeks
• Incentives: food, baby-sitter
• Components for parents, children and the family as a
whole
• Improvement of conduct problems, of emotional
state, of social skills, of parenting skills, of family
functioning and communication.
• Evaluated, replicated, adapted: ES, SE, NL, NO, (IT),
(PT)
• Kumpfer et al., 1996
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Dedalo (Spain)
•
•
•
•
•
Families with pre-adolescent children (aged between 9 and 13)
problems of adaptation and performance at school
early and persistent behavioural problems
Without a need for a specialised therapeutic intervention.
three types of sessions:
•
•
•
Sessions for the parents.
Sessions for the children.
Sessions in which the parents and children jointly participate.
• 13 weeks plus a monitoring session for the parents one month
after the standard sessions have been completed.
• 20 sessions of 90 minutes each - 10 sessions for parents, 6 for
children and 4 joint sessions
• The parents therefore participate in a total of fourteen sessions
and the children in a total of ten.
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Cannabis
• European initiative: Incant project
• Belgium, France, Germany, the Netherlands
and Switzerland explore the value of
Multidimensional Family Therapy (MDFT)
with cannabis users.
• Expanded into a multi-site, randomised
controlled trial comparing MDFT to standard
treatments for cannabis disorders
• Swedish study: no benefit for Swedish system
(Sundell 2006)
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Indicated prevention
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The prevention “filters”: intervention criteria
Universal prevention
no filter
Filter I: social, demographic predictors
(no prediction on individual risk)
Filter II: expert-diagnosed risk
factors: individual mental
health or conduct problems;
drug use not obligatory
Selective prevention
“Filter“: drug
use alone
as predictor
Indicated prevention
Early intervention
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Individual-based Risk Factors
•
•
•
•
•
•
•
Being male
Have alcohol or drug abusing parents
Early onset of substance misuse and petty crime
Aggressive Behaviour (in early childhood)
Other behavioural disorders (ADHD, ODD, CD)
Impulsiveness, Sensation seeking
Social fears and internalising disorders (dual
pathway hypothesis)
• Cognitive difficulties
•
Gerra 2003; Wills et al., 1996-2001; Moffit, 1993; Poikolainen, 2002
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Is early substance use a predictor or a mediator?
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Trajectories to guide Public Health prevention
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“Adolescents make a lot of
decisions that the average 9year-old would say was a dumb
thing to do.”
Control
Motivation/drive
Memory/conditioning
Reward/saliency of stimuli
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Source: Serpelloni, Gerra et al. 2003
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Indicated prevention - approaches
• Cognitive-behaviouristic interventions
• Life-skills training, impulse and emotional
control
• (Child-) Psychiatric diagnosis, treatment,
follow-up (paediatrician, social services)
• Contingency training
• Medication
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Indicated prevention in family and schools
• Empecemos – Let’s start, in Galicia (ES)
•
•
programme for children 8 - 10
disruptive behavioural problems in the classroom (impulsiveness, aggressiveness,
attention problems, hyperactivity) and their teachers and parents
• Component for parents (12 sessions). Training programme in
educational techniques for parents, which seeks to promote educational
styles
• Component for children. 19 group sessions in three modules:
•
•
•
Emotions
Cognitive skills for perspective taking and problem solving
Social skills relating particularly to empathy, non-verbal communication and forming
friendships
• Match (NL)
• children 4 - 14
• risk factors: early and persistent antisocial behaviour, alienation, and
rebelliousness
• matches a child at risk to a trained volunteer adult to support the child during
leisure activities within a relationship based on mutual trust.
• To participate in "Match" it is required that the child at risk is not yet involved
in an environment of heavy drug use.
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Not “nature versus nurture”
but bi-directional effects!
DRUG
GENES
ENVIRONMENT
synaptic structure
and function
INTERVENTIONS
stable changes in synaptic structure
stable long-term change in function
ADDICTION
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Authoritative parenting and sensation seeking
• “If we give the marginal interactions the
benefit of the doubt, then authoritative
parenting is more likely to offset sensation
seekers’ proclivity for marijuana use than for
cigarettes. Although authoritative parenting
has definite advantages, these data suggest
that it is limited with 6th through 8th grade
adolescents in offsetting their sensation
seeking tendencies.” Stephenson & Helme
2006
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Mass Media: family might be a safer target
group than adolescents and children
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Mass media – importance in
member states
Rarely – no priority
Only on specific aspects
Only on Cannabis
Frequent – a priority
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Mass Media campaigns
• No autonomy (no request • Few campaigns target
from the target group)
normative beliefs (NL:
“you’re not mad if you
• Justice: low – most harm
don’t smoke Cannabis
among the most
because 80% don’t
“innocent” – (GOA 2006)
either”)
• High risk of harmfulness –
• Older German
Iatrogenity
campaigns: no
• Low risk of stigma
depiction of drugs, only
• Low (or no?) effectiveness
parents as target
on behaviour
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Wrap – up
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Challenges for family-based prevention
• Improve or abandon universal approaches based
on simple parents’ involvement and information
• Big potentials in selective/indicated approaches
for families at risk
• Comprehensive ethical debate on indicated
prevention and neurobiological trajectories
• Instead of automatically recurring to the “stigma” discourse
• Indicated approaches need better service
interaction and cooperation: less contact fears
• Promote “anti-68“ parenting styles? (Authoritative)
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Mind ethic aspects!!
• Noli nocere! ”beware to do no harm”
• Not only effectiveness (NNT) but also NNH (numbers
needed to harm)
• High iatrogenic effects of information provision alone
• Iatrogenic potentials in selective and indicated
prevention
• Wrong assessment and choice of target population
• Contagion effects
• Reinforcement of problem behaviour (deviancy modelling, norm
narrowing)
• Universal approaches have a good (sometimes
better) effect on risk populations and families
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