Transcript Principles Related to

Principles of Prevention
Ken C. Winters, Ph.D.
Professor, Department of Psychiatry, University of Minnesota
Director, Center for Adolescent Substance Abuse Research
[email protected]
www.psychiatry.umn.edu/research/casar/home.htm
Sao Paulo, Brazil
June, 2011
Bom Dia
New Hampshire
Washington
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www.psychiatry.umn.edu/research/casar/home.html
1. Principles of effective prevention from the
National Institute on Drug Abuse
2. Future directions and priorities
1. Principles of effective prevention from the
National Institute on Drug Abuse
2. Future directions and priorities
Clearly Established Principles
• Derived from an extensive literature review of
articles from NIDA funded research
• Reviewed by an expert scientific panel
• Reviewed by a professional practitioner panel
• Resulted in 14 principles
Principles Related to:
Risk and Protective Factors
(Principles 1 – 4)
•
Prevention programs should
1. Enhance protective factors and reverse or reduce
risk factors
2. Address all forms of drug abuse, alone or in
combination
3. Address the drug abuse problems of the local
community by targeting modifiable risk factors and
strengthening protective factors
4. Be tailored to address the risks specific to the
target population
Risk and Protective Factors
Across Problem Domains
Risk
orProtective
Protective
Risk or
factors
Factors
for Adolescents
A positive relationship with parents
Early Sex
Substance Use
Depression





Conflict in the family
School connectedness



Friends who are negative role models


NS
A positive relationship with adults in the
community

Having spiritual beliefs

Engaging in other risky behaviors


•
Source: Robert Blum, MD, MPH
Johns Hopkins University
•

= protective, statistically significant
= risk, statistically significant
Principles Related to:
Prevention Planning
(Principles 5 – 7)
•
Family programs should
5. Enhance family bonding, parenting skills, and
communication
•
School Programs should be specific to the
developmental status of the children
6. Before/during the elementary school years: self control,
emotional awareness, problem solving, communication &
academic readiness/competence
7. Middle, junior high, and high school: peer relations, study
habits and academic support, communication, selfefficacy and assertiveness, drug resistance skills
Optimizing Parenting Practices
Reduce These
Elevate These
Harsh discipline
Consistent discipline
Rejection/neglect
Close family bond
Lax supervision
Monitoring/supervision
Parent/sibling drug use
Anti-drug family rules
High family conflict
Family communication
Parent mental illness or
life stress
Functional family
School Program (Life Skills Training) 6.5 yr
Follow-up: Illicit Drug Use Outcomes
%
35
30
25
20
15
10
5
0
30.1
22.5
21.0
13.3
13.0
9.2
7.7
3.4
Total Illicit
Subst Use
(other than Mj)
Heroin
Exp Group
Hallucinogens Amphetamines
Control Group
Source: Botvin, G.J., Griffin, K.W., Diaz, T., Scheier, L.M., Williams, C., & Epstein, J.A. (2000). Preventing illicit drug use in
adolescents: Long-term follow-up data from a randomized control trial of a school population. Addictive Behaviors, 25, 769-774.
Principles Related to:
Prevention Planning
(Principles 8 – 10)
•
Community Programs
8. Aimed at the general population during key transition
points (e.g, moving to junior high) can be beneficial for
those at all levels of risk
9. That combine 2 or more effective programs (e.g., school
and family component) can be more effective than one
program
10. When using multiple context to implement programs,
policies and practices consistent messages should be
presented across settings
Effects of School Curriculum + Media
Campaign
best results
Percent of
Youth Using
Each
Substance by
Study
Condition at
Wave 4 Posttest
(n = 4,216)
Slater et al. (2006). Combining in-school and community-based media efforts: Reducing marijuana and alcohol
uptake among younger adolescents. Health Education Research, 21, 157-176.
Illustrative Evidence for Family-School Partnership
Intervention
Trajectory for ISFP Condition
Trajectory for Control Condition
First Time Proportion
0.4
0.3
family-school
program
0.2
0.1
0
0 m o.
(Pretest)
6 m o.
(Posttest)
18 m o.
Grade 7
30 m o.
Grade 8
48 m o.
Grade 10
72 m o.
Grade 12
Source: Spoth, Redmond, Shin, & Azevedo (2004). Brief family intervention effects on adolescent substance initiation:
School-level curvilinear growth curve analyses six years following baseline. Journal of Consulting and Clinical Psychology,
72, 535-542.
Principles Related to:
Prevention Program Delivery
(Principles 11 – 14)
11. When a program is selected, the implementation
should retain the core elements of the original
program but local adaptations are necessary
12. Prevention is an on-going effort with repeated
programming over time to reinforce earlier goals and
develop new skills
13. Teacher training in classroom management is a critical
school-based prevention strategy
14. Evidence based prevention interventions are cost
effective
Comparisons of Low and High Implementation
Conditions to Controls in Boys’
Classroom-Centered Interventions
p <.05
3
p <.05
2.5
p =.05
p =.11
2
1.5
ns
1
0.5
ns
0
Reading grade 1
Reading grade 2
Low vs Control
Aggressive beh.
grade 1
High vs Control
Source: Ialongo et al., 1999. Ordinate values are t-scores for comparisons.
Schools where Principals are supportive of high quality
teacher implementation of PATHS was associated with
better results on aggressive behavior
Predicted Decrease in Student
Aggression
0
Low Support
High Support
-0.1
- 0.20
-0.2
-0.3
-0.4
-0.5
- 0.55
-0.6
Different Levels of Principal Support
Kam, Greenberg,
& Wells,
Kim,
Greenberg
and2004
Wells, 2004
Cost
Summary of Benefits and Costs (2003 Dollars)
Benefits
Program
Costs
B-C
Early Childhood Education
Nurse Family Partnership
$17,202
$26,298
$7,301
$9,118
$9,901
$17,180
Seattle Soc. Dev. Project
$14,246
$4,590
$9,837
$6,656
$851
$5,805
$0
$1,482
-$1,482
$4,058
$4,010
$48
Strengthening Families
10-14
Intensive Juv. Supervision
Big Brothers/Sisters
(Aos et al., 2004) - WA State Institute of Public Policy
Emerging Principles
• Preventive interventions can have long term
effects
• Preventive interventions can have cross over
effects
• Interventions delivered in early childhood
may alter the life course trajectory in a
positive direction
• High risk populations may benefit the most
from prevention interventions
Preventive Interventions Can Have
Long Term Effects
Probability of Drug Abuse/Depend
Good Behavior Game vs. Controls on Drug Abuse or
Dependence Disorders for Adult Males
.8
GBG (n = 72 )
Controls (n = 134 )
.6
.4
.2
0
1
2
3
4
5
Teacher Ratings of Aggression: Fall of 1st Grade
6
Preventive Interventions Can Have
Cross Over Effects
Life Skills Training Program Six-Year Follow-up:
Cross-over Effect on Driving Behaviors
35
30
p <.01
p <.01
25
20
Intervention
Control
15
10
5
0
Violations
Points
Griffin et al. Prevention Science 2004
10
0.20
0.15
0.10
0.05
0.05
0.10
0.15
Probability of Reporting Suicide Ideation
0.20
Impact of GBG done in 1st and 2nd Grades on
Suicide Ideation by Age 19-23**
15
20
25
5
Age
Standard Setting
GBG
Females
* Not replicated in Cohort 2, although in the beneficial direction
** 2nd young adult follow-up was done after the 1st at age 19-21
10
15
Age
Standard Setting
GBG
Males
20
25
Interventions Delivered in Early
Childhood May Alter the Life Course
Trajectory in a Positive Direction
Effects of Early Family Intervention on Destructive
Behavior
Intervention and control group scores on the Child Behavior Check List Destructive Scale from ages 2 to 4. Effect size at age `3 .64 standard
deviations; effect size at age 4 .45 standard. Error bars represent 95% confidence intervals. Shaw et al., JCCP, 2004
% Internalizing Problems (Self-Report) – Child Age 12
30
20
10
0
Comparison
p = .044, OR = 0.63
Nurse
David Olds, PhD
High Risk Populations May Benefit
The Most From Prevention
Interventions
High Risk Populations Benefit the Most
no hx sexual abuse
hx sexual abuse
1. Principles of effective prevention from the
National Institute on Drug Abuse
2. Future directions and priorities
Future Priorities to Strenghten
Prevention Efforts in the U.S.
1. Continue to focus on social and
environmental factors to impact
change
Minimum Legal Drinking Age (MLDA) and Vehicle
Fatalities Among Young Drivers (16 – 20)
raised MLDA
%
Percent of fatally injured
passenger vehicle drivers age
16 – 20 with positive BACs, by
age 1982 – 2008 (Longthorne
et al., 2010)
Impact of Peer Presence on
Risky Driving in Simulated Context
peer effect
Chein et al., in press
Non-Medical Use of Prescription
Drugs
• The rapid rise in use of club
drugs, methamphetamine,
vicodin, and oxycodone has put a
spotlight on the non-medical use
of prescription drugs.
• Increase by 11% in 2001 compared
to previous year.
• Exceeds combined use of heroin,
cocaine, crack and hallucinogens.
• Internet to blame?
www.24/7pharmacy.com
Future Priorities to Strenghten
Prevention Efforts in the U.S.
1. More focus on social and
environmental factors to impact
change
2. Greater integration of selfregulation skills into prevention
curriculum
Childhood Self-Control as a Predictor of Adult
Substance Use Dependence (Moffitt et al., in press)
• composite self control
score, based on ages 3 11
• adult SUD measured
at age 32
Outcomes were converted to Z-scores and childhood self-control is represented in quintiles.
Teaching Skills in Self-Regulation
• impulse control
• “second” thought
processes
• social decision making
• dealing with risk
situations
• taking healthy risks
Future Priorities to Strenghten
Prevention Efforts in the U.S.
3. Increase emphasis of the
importance of parents as a
prevention agent
Parenting Matters
P
A
R
E
N
T
= Promote activities that capitalize on the strengths of the developing brain.
= Assist children with challenges that require planning.
= Reinforce their seeking advice from adults; teach decision making.
= Encourage lifestyle that promotes good brain development.
= Never underestimate the impact of a parent as a role model.
= Tolerate the “oops” behaviors due to an immature brain.
Future Priorities to Strenghten
Prevention Efforts in the U.S.
3. Increase emphasis of the importance of
parents as a prevention agent
4. Continue efforts on the public policy and
clinical fronts toward the goal of “drugfree youth”.
•
alcohol use in moderation when legal age
(21-years-old)
• Do not legalize more drugs
than the two already legal
• Do not lower the minimum
drinking age
• Strengthen regulation of
medical marijuana laws
• Incentivize communities to
to be a primary resource
for prevention programs
and practices
• Expand SBIRT in schools,
detention centers,
pediatric clinics, and
mental health clinics
Obrigado !!
[email protected]