Principles of Prevention

1. Principles of Prevention Ken C. Winters, Ph.D. Professor, Department of Psychiatry, University of Minnesota Director, Center for Adolescent Substance Abuse Research winte001@umn.edu www.psychiatry.umn.edu/research/casar/home.htm Sao Paulo, Brazil June, 2011

2. Bom Dia

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4. www.psychiatry.umn.edu/research/casar/home.html

5. Principles of effective prevention from the National Institute on Drug Abuse • Future directions and priorities

6. Principles of effective prevention from the National Institute on Drug Abuse • Future directions and priorities

8. 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

9. Principles Related to: Risk and Protective Factors(Principles 1 – 4) • Prevention programs should • Enhance protective factors and reverse or reduce risk factors • Address all forms of drug abuse, alone or in combination • Address the drug abuse problems of the local community by targeting modifiable risk factors and strengthening protective factors • Be tailored to address the risks specific to the target population

10. Risk and Protective Factors Across Problem Domains Risk or Protective Factors Risk or Protective factors for Adolescents • = protective, statistically significant • = risk, statistically significant Source: Robert Blum, MD, MPHJohns Hopkins University

11. Principles Related to: Prevention Planning(Principles 5 – 7) • Family programs should • Enhance family bonding, parenting skills, and communication • School Programs should be specific to the developmental status of the children • Before/during the elementary school years: self control, emotional awareness, problem solving, communication & academic readiness/competence • Middle, junior high, and high school: peer relations, study habits and academic support, communication, self-efficacy and assertiveness, drug resistance skills

12. Optimizing Parenting Practices

13. School Program (Life Skills Training) 6.5 yr Follow-up: Illicit Drug Use Outcomes % 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.

14. Principles Related to: Prevention Planning(Principles 8 – 10) • Community Programs • 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 • That combine 2 or more effective programs (e.g., school and family component) can be more effective than one program • When using multiple context to implement programs, policies and practices consistent messages should be presented across settings

15. Effects of School Curriculum + Media Campaign best results Percent of Youth Using Each Substance by Study Condition at Wave 4 Post-test (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.

16. Illustrative Evidence for Family-School Partnership Intervention family-school program 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.

17. Principles Related to: Prevention Program Delivery (Principles 11 – 14) • When a program is selected, the implementation should retain the core elements of the original program but local adaptations are necessary • Prevention is an on-going effort with repeated programming over time to reinforce earlier goals and develop new skills • Teacher training in classroom management is a critical school-based prevention strategy • Evidence based prevention interventions are cost effective

18. Comparisons of Low and High Implementation Conditions to Controls in Boys’ Classroom-Centered Interventions p <.05 p <.05 p =.05 p =.11 ns ns Source: Ialongo et al., 1999. Ordinate values are t-scores for comparisons.

19. Schools where Principals are supportive of high quality teacher implementation of PATHS was associated with better results on aggressive behavior 0 Low Support High Support -0.1 - 0.20 -0.2 -0.3 Aggression Predicted Decrease in Student -0.4 -0.5 - 0.55 -0.6 Different Levels of Principal Support Kim, Greenberg and Wells, 2004 Kam, Greenberg, & Wells, 2004

20. Cost (Aos et al., 2004) - WA State Institute of Public Policy

21. 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

22. Preventive Interventions Can Have Long Term Effects

23. .8 GBG (n = 72 ) Controls (n = 134 ) .6 .4 Probability of Drug Abuse/Depend .2 0 1 2 3 4 5 6 Teacher Ratings of Aggression: Fall of 1st Grade Good Behavior Game vs. Controls on Drug Abuse or Dependence Disorders for Adult Males

24. Preventive Interventions Can Have Cross Over Effects

25. Life Skills Training Program Six-Year Follow-up: Cross-over Effect on Driving Behaviors p <.01 p <.01 Griffin et al. Prevention Science 2004

26. Impact of GBG done in 1st and 2nd Grades on Suicide Ideation by Age 19-23** Males 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

27. Interventions Delivered in Early Childhood May Alter the Life Course Trajectory in a Positive Direction

28. 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

29. % Internalizing Problems (Self-Report) – Child Age 12 p = .044, OR = 0.63 David Olds, PhD

30. High Risk Populations May Benefit The Most From Prevention Interventions

31. High Risk Populations Benefit the Most no hx sexual abuse hx sexual abuse

32. Principles of effective prevention from the National Institute on Drug Abuse • Future directions and priorities

33. Future Priorities to Strenghten Prevention Efforts in the U.S. • Continue to focus on social and environmental factors to impact change

34. 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) %

35. Impact of Peer Presence onRisky Driving in Simulated Context peer effect Chein et al., in press

36. 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

37. Future Priorities to Strenghten Prevention Efforts in the U.S. • More focus on social and environmental factors to impact change • Greater integration of self-regulation skills into prevention curriculum

38. 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.

39. Teaching Skills in Self-Regulation • impulse control • “second” thought processes • social decision making • dealing with risk situations • taking healthy risks

40. Future Priorities to Strenghten Prevention Efforts in the U.S. • Increase emphasis of the importance of parents as a prevention agent

41. Parenting Matters P= Promoteactivities that capitalize on the strengths of the developing brain. A= Assistchildren with challenges that require planning. R= Reinforcetheir seeking advice from adults; teach decision making. E= Encouragelifestyle that promotes good brain development. N= Neverunderestimate the impact of a parent as a role model. T= Toleratethe “oops” behaviors due to an immature brain.

42. Future Priorities to Strenghten Prevention Efforts in the U.S. • Increase emphasis of the importance of parents as a prevention agent • 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)

43. 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

44. Obrigado !!winte001@umn.edu