Transcript AAHB02 Laureate presentation

Broadening Prevention Research:
Linking Schools, Families, and
Communities in Promoting Positive
Behavior, Character, Mental Health and
Academic Achievement
Brian R. Flay, D.Phil., FSBM, FSCRA, FAAHB
Distinguished Professor
Health Research and Policy Centers University of
Illinois at Chicago
Presented at American Academy of Health Behavior Conference
in acceptance of the Research Laureate Award
Napa, CA, March 25, 2002
UIC
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Illinois at Chicago
AAHB Conference, Napa, CA, March 25, 2002
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Outline of Presentation
1. The importance of linking behavior, character, mental
health, and academic achievement
2. Behaviors are related.
Also predict and are predicted by each other
Must work towards a comprehensive, coherent, integrated approach to youth
development.
3. All behaviors have common predictors/causes
Risk and Protective Factors
The Theory of Triadic Influence (Integrates theories)
Importance of Community, Family and School
Must work toward comprehensive and coherent classroom, school-wide, family
and community programs
4. Implications for prevention science, programs and policies
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PART 1:
The importance of linking
behavior, character,
mental health and
academic achievement
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Linking behavior, character, mental
health and academic achievement are
important because ...
• Demands on education require that prevention be tied to
academic achievement
• Most prevention and promotion programs to date have
neglected the link with academic achievement
– Exceptions: Hawkins & Catalano, Positive Action (Carol Allred),
Weissberg’s recent statements re Social-Emotional Learning
• Academic Achievement depends, in part, on positive youth
development
– Most prevention researchers recognize that early school failure
predicts later problem behavior, but rarely the reverse
• Prevention needs to fit into the whole educational picture of
improving student behavior, character and achievement.
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Other factors demanding
positive youth development
• Most education dollars target reading and testing
– E.g., $900 million to “Reading First”
– This is probably short-sited
– Education is in crisis
• Loud calls/demands for science-based programs of proven
effectiveness
– Is our science of effectiveness advanced enough?
• Increasing demands for community-based and after-school
programs
– Communities are in crisis
– But don’t leave out schools. Education is key to youth development.
• Positive youth development
• = Positive behavior, character, mental health, academic achievement
• = A successful and happy life
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Unfortunately ... Behaviors that
prevent success and happiness
are far too prevalent among
youth today
• Problem/Risky Behaviors
– Substance use and abuse, violence, and unsafe sex
• Other health-compromising behaviors
– Poor eating habits and inadequate physical activity
•
•
•
•
UIC
Unacceptable and anti-social behavior
Poor character development
Psychological and mental disturbances
School failure
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Trends in Annual Prevalence of an Illicit Drug Use Index
Eighth, Tenth, and Twelfth Grades, 1975-2001.
Monitoring the Future data, http://monitoringthefuture.org
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Violence among our Youth
• On a typical day, 6 or 7 youth are slain in this country, mostly inner-city,
minority youth.
• Males account for more than 90% of incidents involving those 10-17
years of age.
• Handgun homicides committed by young males (15-18) between 1980
and 1995 increased by more than 150%.
• Youth are three times more likely than adults to be victims of violence.
• 5% of students reported feeling too unsafe to attend school at least
once in the thirty days preceding the National Youth Risk Behavior
Survey.
• 20% of high school students reported carrying a weapon (e.g., gun,
knife, or club) at least once in the thirty days preceding the National
Youth Risk Behavior Survey.
• ~8% reported carrying a gun, and 10% reported having carried a
weapon on school property on one or more occasions in those 30 days.
–
UIC
Factoids from Center for the Study and Prevention of Violence, U Colorado,
www.colorado.edu/cspv/factsheets
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Teen sexual behavior?
• One quarter of high school freshman girls and just over
half (52%) of senior girls have had sex.
• Almost a third (27%) of high school freshman boys and
almost two-thirds (59%) of senior boys have had sex.
• Nearly 9 of 10 students enrolled in alternative high
schools have had sex.
• Only about 1 in 5 young people do not have intercourse
while teenagers.
– Factoids from ETR:
UIC
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www.etr.org/recapp/stats
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Mental Health Statistics for Children
•
•
•
•
•
•
UIC
One in five children have a diagnosable mental, emotional or
behavioral disorder. And up to one in 10 may suffer from a serious
emotional disturbance (SGRMH, 2001).
Attention deficit hyperactivity disorder (ADHD), one of the most
common mental disorders in children, affects 3 to 5 percent of
school-age children (NIMH, 1999).
As many as one in every 33 children and one in eight adolescents
may have depression, more likely for girls than boys (CMHS, 1998).
Children and teens who have a chronic illness, endure abuse or
neglect, or experience other trauma have an increased risk of
depression (NIMH, 2000).
Once a child experiences an episode of depression, he or she is at
risk of having another episode within the next five years (CMHS,
1998).
More than half of young persons with a substance abuse diagnosis
also have a diagnosable mental illness (NAMI, 2001).
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Conclusion #1:
• Prevention research, program
development, and dissemination must
– Link multiple behaviors with school success
or failure
– Link prevention with other educational
functions (mental health and achievement)
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PART 2:
Behaviors are
Highly Correlated
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Substance Use and Abuse Behaviors are
Highly Correlated and Predict Each Other
Alcohol
Tobacco
Illicit
Substance
And can be
thought of as a
latent variable
Ab/Use
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Problem/Risky Behaviors are
Highly Correlated and Predict Each Other
Threats
Fighting
Illicit
Alcohol
Tobacco
Substance
Weapons
Early
Interpersonal
Violence
No Condoms
Unsafe
Ab/Use
Multiple
partners
Sex
Problem/
Risky
Behavior
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Mental Health Behaviors are
Highly Correlated and Predict Each Other
Conduct
Disorder
Anxiety/
Depression
ADHD
Mental
Health
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Health-Promoting Behaviors are
Highly Correlated and Predict Each Other
Sports
Walking
Exercise
Visits
Teeth
Hygiene
Junk
Meat/Dairy
Physical
Activity
Health
Eating/
Care
Diet
Fruits &
Veges
Healthy
Behaviors
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Conventional/Social Behaviors are
Highly Correlated and Predict Each Other
School
Home
Community
Family
School
Family
School
Skills
Obey Rules
Academic
Achievement
and Laws
Community
Bonding &
Involvement
Service
Voting
Sport/
Cultural
Conventional
and Social
Behaviors
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Positive, Health and Social Behaviors are
Highly Correlated and Predict Each Other
Conduct
Anxiety
/Dep
Health
Care
Physical
ADHA
Eating/Diet
Mental
Health
Safe Sex
Healthy
Behaviors
Community
Bonding
Law Abiding
Nonviolent
No Drugs
Achievement
Low Risk,
non-Problem
Behaviors
Conventional
and Social
Behaviors
Successful
and Happy
Citizens
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Conclusion #2
Future prevention programs need to comprehensively
and coherently address multiple behaviors and
outcomes
- Prevention of Problem/Risky Behaviors
Substance use and abuse, violence, and unsafe sex
- Promotion of health-enhancing behaviors
Good eating habits and adequate physical activity
- Psychological and mental health
- Positive character development
Positive moral and social behavior
-School success
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BUT, should we target single
or multiple behaviors?
- We used to believe that effects would be larger if we
targeted a single behavior, or a single domain, such as
substance use
- Increasing evidence that many behaviors and domains
are interrelated, and that programs should deal with
them together
- Increasing evidence that programs that address
multiple issues are effective
- Particularly if they address related issues -- problem
behaviors, health behaviors, school behaviors
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Two Programs As Examples
• ABAN AYA
– Who: Flay et al., University of Illinois
– What: Social & Emotional Skills Development
• Double Protection (ABAN) and Self-Determination (AYA!)
– Why: Violence, Drug Use, Unsafe Sex
– Where: Inner-city African-American Schools
• POSITIVE ACTION
–
–
–
–
UIC
Who: Carol Allred, Twin Falls, ID
What: Comprehensive Character Education & SEL
Why: Improve all behaviors and academics
Where: 8,000 schools nationwide and internationally
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UIC
Illinois at Chicago
University of
AAHB Conference,
CA,Proj
March
25,
2002
C opyri ghtNapa,
Aban Aya
ec t, UIC
, 2001
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Health University
Researchof
Illinois
Chicago
and Policy at
Centers
ABAN AYA
Classroom Content
•
INFORMATION
•
– Prevalence and nature of
risky behaviors
– Consequences of engaging in •
risky behaviors
– On the proper use of
medicines
•
SOCIAL INFLUENCES
– Awareness of social
•
influences from peers, family,
media, etc
– Corrections of normative
misperceptions
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PROBLEM SOLVING
– Decision making
– Goal setting
SOCIAL SKILLS
–
–
–
–
Assertiveness/Resistance skills
Risk management or avoidance
Conflict resolution, mediation
Social networking
CULTURAL PRACTICES AND VALUES
– Cultural pride/history (Kwanzza Nguzo Saba)
– Articulation of community roles
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Violence: Predicted Means
15
14
13
12
11
10
0
Control
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3
2
1
4
Treatment
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ABAN AYA significantly
improved multiple behaviors
•
•
•
•
•
•
•
•
•
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Physical Violence
Provoking Behavior
Alcohol and Drug Use
School Delinquency
Frequency of sexual intercourse
Condom Use
Healthy & junk food consumption
Physical Exercise
Standardized Test Scores
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ABAN AYA significantly
improved multiple behaviors …
Though only for males!
•
•
•
•
•
•
•
•
•
UIC
University of
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Physical Violence
Provoking Behavior
Alcohol and Drug Use
School Delinquency
Frequency of sexual intercourse
Condom Use
Healthy & junk food consumption
Physical Exercise
Standardized Test Scores
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Males’ behavior was brought down
to the level of females’ behavior
15
14
13
12
11
10
9
8
0
0.5
1
Males C
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1.5
2
Males Tx
AAHB Conference, Napa, CA, March 25, 2002
2.5
3
3.5
All Females
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After adjusting for pretest differences, there were also
effects on standardized test scores (males & females)
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The Positive Action Program
Targets Multiple Behaviors
• By teaching that doing positive actions helps:
– individuals develop a positive self identity.
– families develop a positive family identity.
– schools develop a positive school identity.
o u g hts
Th
– communities develop a positive community
identity.
F
e
e
li
n
g
s
• By teaching that:
s
n
o
ti
c
A
– When you do good, you feel good
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In the classroom curriculum and in all other
materials, the Positive Action content is
taught school-wide through six units:
• Unit 1. Self-Concept: What It Is, How It’s Formed, and
Why It’s Important.
• Unit 2. Physical and Intellectual Positive Actions for
Body and Mind
• Unit 3. Social/Emotional Positive Actions for Managing
Yourself Responsibly
• Unit 4. Social/Emotional Positive Actions for Getting
Along with Others by Treating Them the Way You Like
to be Treated (Character Education)
• Unit 5. Social/Emotional Positive Actions for Being
Honest with Yourself and Others (Mental Health)
• Unit 6. Social/Emotional Positive Actions for Improving
Yourself Continually
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And Has Multiple Effects:
Effect Sizes and percent improvement for
Positive Action (with training)
and other social and skills-based programs
Positive Action
Others
ES
%
ES
%
Drug Use
0.54
26
0.24
12
Violence
1.49
60
0.16
8
Disciplinary
1.79
67
--
--
Absenteeism
0.41
20
--
--
Reading
0.58
28
0.5
25
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PART 3:
All Behaviors
Have Common
Predictors/Causes
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All Behaviors Have Common Causes
PERSONAL
SELF-EFFICACY
Genetic
Personality
SITUATIONAL
SOCIAL
NORMATIVE
BELIEFS
ENVIRONMENTAL
VALUES/
ATTITUDES
Community
Family
School
Broader sociocultural environment
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All Behaviors Have Common Causes:
The Basics of the Theory Of Triadic Influence
DNA
Social
Competence
& Personality
Social
Skills
Sense of
Self
Self
Determination
Others'
Beh&&Atts
Decisions/
Intentions
Perceived
Norms
Social
Context
Bonding
SELF
EFFICACY
Motivation
to Comply
SOCIAL
NORMATIVE
BELIEFS
BEHAVIOR
Values
Values ATTITUDES
Evaluations
Evaluations
Culture
Religion
Knowledge
Expectancies
Informational
Environment
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Not to be confused with ...
my Audi TT
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References re TTI
• Petraitis, J., Flay, B.R., & Miller, T.Q. Reviewing theories of adolescent
substance abuse: Organizing pieces of the puzzle. Psychological
Bulletin, 117(1), 67-86. 1995.
• Flay, B.R. & Petraitis, J. The theory of triadic influence: A new theory
of health behavior with implications for preventive interventions. In
Albrecht, G.S. (ed.) Advances in Medical Sociology, Vol IV: A
Reconsideration of models of health behavior change (pp. 19-44).
Greenwich, CN: JAI Press, 1994.
• Flay, B.R., Petraitis, J., Hu, F. The theory of triadic influence:
Preliminary evidence related to alcohol and tobacco use. In Fertig,
J.B., Allen, J.P. (eds.) NIAAA Research Monograph - Alcohol and
Tobacco: From Basic Science to Clinical Practice (pp. 37-57).
Bethesda, MD: U.S. Government Printing Office, 1995.
• Flay, B.R. Understanding environmental, situational and intrapersonal
risk and protective factors for youth tobacco use: the Theory of
Triadic Influence. Discussant Comments. Nicotine & Tobacco
Research, 1, S111-S114, 1999.
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EVERYBODY NOW ….
“All Behaviors Have Common Causes”
National
Socio-Cultural
Environment
Political, Economic,
Media, Religious.
Local Community,
Families, Schools
Intrapersonal
Biology,
Personality
Relationships with Others.
Others’ Attitudes, Behaviors.
Social Normative Beliefs
Self-Concept,
Social Skills.
Values, Attitudes
Self-Efficacy
Risky Behavior, Healthy Behavior, Mental Health, Academics
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All Behaviors Have Common Causes
Local Community,
Families, Schools
National
Socio-Cultural
Environment
Political, Economic,
Media, Religious.
Intrapersonal
Biology,
Personality
Relationships with Others.
Others’ Attitudes, Behaviors.
Self-Concept,
Social Skills.
Social Normative Beliefs
Values, Attitudes
Self-Efficacy
Physical
Safe Sex
Health
Care
Physical
Eating/Diet
Nonviolent
No Drugs
Health
Care
Low Risk,
non-Problem
Behaviors
Community
Bonding
Eating/Diet
Mental
Health
Healthy
Behaviors
Conventional
and Social
Behaviors
Law Abiding
Achievement
Successful and Happy Citizens
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BUT, Note the Critical Importance
of Community, Family and School
Community
Family & School
Relationships with Others.
Others’ Attitudes, Behaviors.
Values, Attitudes
Social Normative Beliefs
Self-Efficacy
Risky Behavior, Healthy Behavior, Mental Health, Academics
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The Critical Importance of
Community, Family and School
Community
Family
School
Student Health,
Behavior and
Academic
Performance
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Conclusion #3
Future prevention programs need to involve whole schools,
families and communities in an integrated and coherent way
- Classroom curricula can teach content and skills
Should be school-wide, scoped and sequenced for every grade
- Teacher training can address
class/behavior management and teaching effectiveness
- School-wide climate change can provide
a safe learning environment
provide common language and consistently reinforce desired behaviors
- Family programs can
improve parenting skills
provide common language and consistently reinforce positive behaviors
- Community programs can
link schools and communities
get students observing and doing community service
provide common language and consistently reinforce positive behaviors
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ABAN AYA:
INTENSIVE SCHOOL/COMMUNITY INTERVENTION
•
•
•
•
•
•
•
UIC
Comprehensive classroom program
Enhanced parent involvement
Parent Training/Education
School Health Promotion Task Force
School-wide staff development
Community-Based Organization involvement
Institutionalization in schools & communities
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ABAN AYA: SDC and SC Effects on Males by 8th Grade
Construct and model
Curriculum Estimate
Growth
Std
Reduction
Err
(%)*
0.53
35
0.60
47
Program effect
Effect
p†
size ‡
0.026
0.31
0.008
0.41
Violence
Continuous outcome, mixed
SDC
SC
2.8
2.2
Provoking
Continuous outcome, mixed
SDC
SC
3.4
2.3
0.98
1.15
40
59
0.059
0.017
0.27
0.40
School delinquency
Continuous outcome, mixed
SDC
SC
2.1
1.3
0.32
0.35
27
54
0.049
0.001
0.25
0.49
Substance use
Ordinal outcome, GEE
SDC
SC
1.5
1.3
0.28
0.31
37
47
0.016
0.005
0.50
0.63
Recent sexual intercourse
Binary outcome, GEE
SDC
SC
1.0
0.6
0.27
0.34
44
65
0.039
0.009
0.44
0.65
Condom use
Ordinal outcome, GEE
SDC
SC
1.4
1.9
0.47
0.41
95
165
0.138
0.022
0.38
0.66
SDC
SC
SC-SDC
4.7
7.9
3.2
1.66
1.82
1.77
0.002
<.0001
0.036
0.37
0.62
0.35
Combined model
Continuous outcome,
doubly-repeated measures
* [HEC growth - (SDC or SC growth)] / HEC growth. For condom use % increase is shown.
† p-values are 1-tailed.
‡ Effect size for GEE models is [HEC - (SDC or SC) growth] / √(π2/3)
§ Combined model effect size accounts for variance between behaviors.
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The POSITIVE ACTION Program Components
K–12 classroom curriculum
over 1,200 lessons - using Teacher’s Kits (manuals and materials for each
grade), classroom teachers present 15–20-minute lessons
Principal’s Kits (Elementary and Secondary)
a school-climate program to promote the practice and reinforcement of
positive actions in the whole school population (students and staff)
Counselor’s Kit
used with selected individual students, small groups and families
Family Kit
contains prepared weekly home lessons paralleling the school program
along with school parent-involvement activities
Community Kit
manuals and materials that align and encourage collaboration of all the
environments (schools, families and community) involved in the program
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And Has Multiple Effects:
Effect Sizes and percent improvement for
Positive Action (with training)
and other social and skills-based programs
Positive Action
Others
ES
%
ES
%
Drug Use
0.54
26
0.24
12
Violence
1.49
60
0.16
8
Disciplinary
1.79
67
--
--
Absenteeism
0.41
20
--
--
Reading
0.58
28
0.5
25
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PART 4:
Challenges for
Prevention Science,
Prevention Programs
and Education
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Is Prevention Science
Up To The Challenges Of ...?
Developing comprehensive interventions
That are multi-component, broad-based, deep-structured, and coherent
Evaluating comprehensive interventions
Is very difficult and complex
And is very expensive
Getting schools to do the seemingly
impossible
Be successful in improving multiple behaviors as well as character
and achievement
Translating research into practice
So that it is replicable
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What’s at stake if we don’t meet
these challenges?
Disenchantment with prevention
The credibility of prevention researchers
Prevention funding for schools
Increased problems for our children
More adolescent SU, violence, unsafe sex
Declining virtues, morals, etc.
Decreasing academic achievement and increasing school failure
Increasing failures to succeed in life
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Limitations of Most Programs
• Domain Specific
– Usually only one behavior or one skill
• Start too late
– Upper elementary or middle school
• Limited intensity and dose
– Often only once a week for 10-20 sessions
• Ecologically Limited
– Usually only classroom.
– Also need school-wide, parent, community
• Limited Effect Sizes
– Average effect sizes in the 0.2 to 0.4 range
• Effects not Sustained
– Few effects beyond one year, let alone H. S.
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Conclusion #4
• All of the foregone has implications for:
– Prevention and Education Programs
– Prevention and Educational Policy
– Prevention and Education Research
UIC
University of
Illinois at Chicago
AAHB Conference, Napa, CA, March 25, 2002
53
Health Research
and Policy Centers
Promotion Programs of the Future
Must Be Characterized As …
• EARLY AND OFTEN
– Start early, scoped and sequenced, many doses, over a long time
• POSITIVE
– Focus on asset and strength development
– Address protective factors more than risk factors
– Include positive reinforcement and environmental contingencies
• COMPREHENSIVE
– Multiple domains: behaviors, feelings, thoughts, character, achievement
– Multiple protective/risk factors
– Multiple levels: students, teachers, school, families, community
• REPLICABLE
– Diverse teaching strategies
– Complete materials, user friendly
– Minimal training required, but necessary training easily provided
• EFFECTIVE
– Large effects that are sustained
UIC
University of
Illinois at Chicago
AAHB Conference, Napa, CA, March 25, 2002
54
Health Research
and Policy Centers
Future Educational
Promotion Policy Must ...
• Focus on positive child/youth development
• Rather than focusing on negative behaviors and failures
• Prefer more integrated, comprehensive, coherent, holistic
approaches
• Rather than separate, piece-meal approaches to different issues
• Support longer-term, more comprehensive
research/evaluation
• Rather than shorter-term, limited studies
• This will require prevention/promotion to align with
character education and achievement
UIC
University of
Illinois at Chicago
AAHB Conference, Napa, CA, March 25, 2002
55
Health Research
and Policy Centers
Future Promotion Researchers will ...
1. Analyze for whom programs are most and least
effective.
2. Conduct mediation and other analyses to help us
understand mechanisms of action.
3. Show long-term effects with school-level data.
4. Have a broader view of acceptable approaches to
research.
5. Consider larger replicated effects to be more
important than findings from any one study.
6. Conduct more effectiveness trials.
7. Conduct cost-effectiveness analyses.
UIC
University of
Illinois at Chicago
AAHB Conference, Napa, CA, March 25, 2002
56
Health Research
and Policy Centers
Not OR but AND
Science AND Passion
Risk Factors AND Protective Factors
White, middle-class AND Diverse cultures
Genetic/Intrapersonal AND Social/Environmental
Individually focussed AND System/Environment
Research Based AND Real World Derived
Scientific Rigor AND Program Characteristics
Courtesy Tony Biglan and colleagues, Stanford Center for Advancement of Behavioral Sciences, 3/01
UIC
University of
Illinois at Chicago
AAHB Conference, Napa, CA, March 25, 2002
57
Health Research
and Policy Centers
SUMMARY
• It is critically important to link behavior, character, mental
health, and academic achievement
• Positive, problem, health, and mental health behaviors are
all related, and are all related to character and academic
achievement
• All behaviors and related outcomes have the same
causes, many of which reside in families, schools and
communities
• Future prevention/promotion research, programs, and
policies need to be comprehensive, integrated and
coherent across behaviors, grades/ages, and social
ecologies (schools, homes and communities)
UIC
University of
Illinois at Chicago
AAHB Conference, Napa, CA, March 25, 2002
58
Health Research
and Policy Centers
Have
A Positive Action
Evening.
And A Happy and
Successful Life.
UIC
University of
Illinois at Chicago
AAHB Conference, Napa, CA, March 25, 2002
59
Health Research
and Policy Centers