principles of prevention ken c. winters, ph.d. professor, department of psychiatry, university of...
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Principles of Prevention
Ken C. Winters, Ph.D.Professor, Department of Psychiatry, University of
MinnesotaDirector, Center for Adolescent Substance Abuse
Research
[email protected]/research/casar/home.htm
Sao Paulo, BrazilJune, 2011
Bom Dia
Indiana
Kansas
MaineMontana
NebraskaNevada
North Dakota
Puerto Rico
Hawaii
New Mexico
South Dakota
Alabama
Arkansas
Iowa
Oklahoma
Rhode Island
South CarolinaDistrict Of ColumbiaTennessee
Utah
Louisiana
W. Virginia
Minnesota
Wisconsin
New Jersey
North Carolina
Alaska
Delaware
Maryland
Pennsylvania
Georgia
KentuckyVirginia
MichiganNew York
Oregon
Colorado
Texas
New Hampshire
Connecticut
Illinois
Missouri
Arizona
Florida
Ohio
Vermont
Idaho
Massachusetts
California
Washington
Wyoming
Mississippi
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
Risk and Protective Factors(Principles 1 – 4)
• Prevention programs should1. Enhance protective factors and reverse or
reduce risk factors2. Address all forms of drug abuse, alone or in
combination3. 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
Principles Related to:
Risk and Protective Factors Across Problem Domains
Risk or Protective factors Risk or Protective factors for Adolescentsfor Adolescents Early Sex Substance Use Depression
A positive relationship with parents
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
• = protective, statistically significant
• = risk, statistically significantSource: Robert Blum, MD, MPHJohns Hopkins University
Risk or Protective Factors
Prevention Planning(Principles 5 – 7)
• Family programs should5. Enhance family bonding, parenting skills, and
communication• School Programs should be specific to the
developmental status of the children6. 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, self-efficacy and assertiveness, drug resistance skills
Principles Related to:
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
22.5
3.4
13.09.2
30.1
7.7
21.0
13.3
05
101520253035
Total IllicitSubst Use
(other than Mj)
Heroin Hallucinogens Amphetamines
Exp Group 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.
%
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
Principles Related to:
Effects of School Curriculum + Media Campaign
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.
Percent of Youth Using Each Substance by Study Condition at Wave 4 Post-test (n = 4,216)
best results
Illustrative Evidence for Family-School Partnership Intervention
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.
0
0.1
0.2
0.3
0.4
0 mo.(Pretest)
6 mo.(Posttest)
18 mo.Grade 7
30 mo.Grade 8
48 mo.Grade 10
72 mo.Grade 12
Fir
st
Tim
e P
rop
ort
ion
Trajectory for ISFP Condition
Trajectory for Control Condition
family-schoolprogram
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
Principles Related to:
Comparisons of Low and High Implementation Conditions to Controls in Boys’
Classroom-Centered Interventions
0
0.5
1
1.5
2
2.5
3
Reading grade 1 Reading grade 2 Aggressive beh.grade 1
Low vs Control High vs Control
p <.05
p <.05
ns
ns
p =.11
p =.05
Source: Ialongo et al., 1999. Ordinate values are t-scores for comparisons.
Kam, Greenberg, & Wells, 2004
Low Support High Support
Schools where Principals are supportive of high qualityteacher implementation of PATHS was associated with
better results on aggressive behavior
-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0
Different Levels of Principal Support
Pre
dic
ted
De
cre
as
e i
n S
tud
en
t
Ag
gre
ss
ion
- 0.20
- 0.55
Kim, Greenberg and Wells, 2004
Cost
Summary of Benefits and Costs (2003 Dollars)
Program Benefits Costs B - C
(Aos et al., 2004) - WA State Institute of Public Policy
Early Childhood Education $17,202 $7,301 $9,901
Nurse Family Partnership $26,298 $9,118 $17,180
Seattle Soc. Dev. Project $14,246 $4,590 $9,837
Strengthening Families 10-14
$6,656 $851 $5,805
Intensive Juv. Supervision $0 $1,482 -$1,482
Big Brothers/Sisters $4,058 $4,010 $48
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
Good Behavior Game vs. Controls on Drug Abuse or Dependence Disorders for Adult
Males
0
.2
.4
.6
.8
1 2 3 4 5 6
Pro
babi
lity
of D
rug
Abu
se/D
epen
d
Teacher Ratings of Aggression: Fall of 1st Grade
GBG (n = 72 )Controls (n = 134 )
Preventive Interventions Can Have Cross Over Effects
0
5
10
15
20
25
30
35
Violations Points
Intervention
Control
Life Skills Training Program Six-Year Follow-up:Cross-over Effect on Driving Behaviors
p <.01p <.01
Griffin et al. Prevention Science 2004
Impact of GBG done in 1st and 2nd Grades on Suicide Ideation by Age 19-23**
0.0
50.1
00.1
50.2
0P
rob
abili
ty o
f R
epo
rtin
g S
uic
ide
Ide
ation
10 15 20 25Age
Standard SettingGBG
0.0
50.1
00.1
50.2
0P
rob
abili
ty o
f R
epo
rtin
g S
uic
ide
Ide
ation
5 10 15 20 25Age
Standard SettingGBG
MalesFemales* Not replicated in Cohort 2, although in the beneficial direction** 2nd young adult follow-up was done after the 1st at age 19-21
Interventions Delivered in Early Childhood May Alter the Life
Course Trajectory in a Positive Direction
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
Effects of Early Family Intervention on Destructive Behavior
% Internalizing Problems (Self-Report) – Child Age 12
0
10
20
30
Comparison Nurse
p = .044, OR = 0.63 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
1. Continue to focus on social and environmental factors to impact change
Future Priorities to Strenghten Prevention Efforts in the U.S.
Percent of fatally injured passenger vehicle drivers age 16 – 20 with positive BACs, by age 1982 – 2008 (Longthorne et al., 2010)
%
raised MLDA
Minimum Legal Drinking Age (MLDA) and VehicleFatalities Among Young Drivers (16 – 20)
Impact of Peer Presence onRisky Driving in Simulated Context
Chein et al., in press
peer effect
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
1. More focus on social and environmental factors to impact change
2. Greater integration of self-regulation skills into prevention curriculum
Future Priorities to Strenghten Prevention Efforts in the U.S.
Childhood Self-Control as a Predictor of Adult Substance Use Dependence (Moffitt et al., in press)
Outcomes were converted to Z-scores and childhood self-control is represented in quintiles.
• composite self control score, based on ages 3 - 11
• adult SUD measured at age 32
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 = Promote activities that capitalize on the strengths of the developing
brain.
A = Assist children with challenges that require planning.
R = Reinforce their seeking advice from adults; teach decision making.
E = Encourage lifestyle that promotes good brain development.
N = Never underestimate the impact of a parent as a role model.
T = 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 “drug-free 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
