Evolving Statewide Comprehensive Preventive Practices

1. Evolving Statewide Comprehensive Preventive Practices Anthony Biglan Oregon Research Institute tony@ori.org

2. A broad consensus has emerged about the conditions that are needed to prevent most problems of childhood and adolescence and to ensure that nearly every young person develops successfully.

3. Advancingthe Prevention of Mental, Emotional, and Behavioral Disorders

4. Research over the Past 30 Years Shows What Is Possible Young people reach adulthood with all of the skills, interests, assets, and health habits needed to live happy and productive lives in caring relationships with other people

5. Explosion of Randomized Trials

6. Psychological and Behavioral Problems Co-Occur • 8th grade behaviors such as: • substance use • antisocial behavior • sexual behavior • and depression are 4.3 times more likely to occur together than to occur separately

7. In Order to Nurture Successful Development We Need to: • Minimize toxic conditions • Promote and richly reinforce prosocial behavior • Limit opportunities for problem behavior • Promote psychological flexibility—the ability to hold your thoughts and feelings lightly and act in the service of your value

8. The Effectiveness of Prevention

9. The Importance of Nurturing Self-Regulation • Children who do not develop the capacity to inhibit impulsive behavior, to plan, and to regulate their emotions are at high risk for behavioral and emotional difficulties

10. Moffitt et al. (2011) • Examined self-control: ability to delay gratification, control impulses, and modulate emotional expression. • Followed a cohort of 1000 children from birth to age 32 • Childhood self-control predicted physical health, substance dependence, personal finances, and criminal offending outcomes.

12. Nurse-Family Partnership* • Pregnancy through infancy • Focus on • Prenatal care • Maternal smoking • Mothering • Contraception • Work life * Funded in part by NIDA

13. Nurse-Family Partnership • Evaluated in three randomized trials for poor, teenager single mothers, • Significant effects on • Abuse and neglect • Children’s behavioral development • Mother’s economic wellbeing • Time to next baby • Children’s arrest as adolescent

14. Adjusted rates of arrests, 15-year olds, Elmira PC-NP & C-NPI = .005

15. Positive Parenting Program—Triple P* • A community-wide system of parenting supports that includes • brief media communications, • brief advice for specific problems, and • more extensive interventions when needed • Multiple randomized trials showing benefit • Including an RCT in 18 counties in South Carolina * Funded in part by NIDA

16. Substantiated Child Maltreatment Effect size = 1.09, p <.03. Triple P stopped a rising trend of substantiated child-maltreatment in counties using Triple P, compared to counties not receiving Triple P. Before Triple P After Triple P

17. The Family Check-Up* • Provides parenting support to families of adolescents via a family resource center in middle schools • Effects as much as five years later • Reduced substance use • Fewer arrests • Better school attendance & academic performance • Cost-effectiveness (Aos et al., 2004) • Savings of $5.02 per dollar invested • Total savings of $1,938 per youth

18. Probability of Arrest from Age 11-17 as a Function of Intervention Engagement Ec Ei E N=Non-engaged E=Engaged 11 12 13 14 15 16 17 Age in Years Connell, Dishion et al., 2008

19. The Good Behavior Game* • Classroom teams in elementary school earn small rewards for being on-task and cooperative • Randomized trial in Baltimore Inner City Schools • Had preventive effects even into young adulthood • Substance abuse disorders • Antisocial personality

20. Positive Behavioral Interventions & Supports (PBIS) Model • Systematic approach to implementing and sustaining evidence-base practices for the social success of all youth within a facility. • Cohesive approach to thinking about how to achieve the ultimate goals of an organization by aligning all branches of an organization. • School-based improvements in academic and social behaviors (Horner et al, 2002; Sprague & Golly, 2004). • Improvements in organizational health (Bradshaw et al, 2005) • Randomized trials in Maryland (Bradshaw et al, 2007).

21. PBIS Model: Conceptual foundations • Applied behavior analysis, • Community health multi-tiered prevention model (Walker et al, 1996), • Universal screening and progress monitoring (Fuchs & Fuchs, 1986; Shin, Walker & Stone, 2002), • Merging of social and academic practices (Algozzine & Algozzine, 2009; McIntosh, Horner, Chard, Boland, & Good, 2006), and • Systems technology appropriate to implement effective practices on a large scale (Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005).

22. PBIS Model: Four Main Components Institute on Violence and Destructive Behavior Dr. Jeffrey R. Sprague jeffs@uoregon.edu

23. PBIS Model: Outcomes & Practices • OUTCOMES: • Valued social, behavioral, academic, outcomes your staff is trying to support for the youth within your facilities. • Proximal and distal • PRACTICES: • Day to day practices that support youth in achievement of these outcomes. • Evidence-based practices that meet the specific behavioral needs of your population- which will be varied. • Also includes practices like healthy menus, daily exercise time, etc.

24. PBIS Model: Systems and Data • SYTEMS: • Day to day policies, protocols, trainings, resources that help staff support youth in attainment of the valued outcomes. • DATA: • Progress and outcome information that allows staff to know if those valued outcomes are being achieved. Basis of decision-making.

25. Another way to think about it… Supporting Social Competence & Academic Achievement OUTCOMES DATA Supporting Decision Making PRACTICES Evidence-based, preventive. Supporting Youth Behavior SYSTEMS Supporting Staff Behavior & Implementation Fidelity

26. PBIS Model: Tiers of Support • Alignment of outcomes, practices, systems, & data applied to all tiers of support: • Majority of youth • Small groups of youth • Individual youth • Model doesn’t change • INDIVIDUALIZE AND INTENSIFY

27. PBIS Model • Strengths: • Clarifies expectations • Provide structure • Data based decision making increases accountability and protects youth • Weaknesses: • Often mistaken for it’s parts and not as the whole model • May be viewed as competing with other models • The proactive / preventative nature may be perceived as incongruent with Juvenile Justice aims

28. Positive Action Overview • Positive Action teaches the positive actions for the whole self through six units that are contained in six program components. • Teacher/staff training • K-12 curriculum • Climate development • Counselors program • Family program • Community program

31. Prevention of Depression • Clarke et al. (2001) found that a group program for adolescent offspring of depressed parents could reduce the incidence of depression to a level no higher than for adolescents whose parents were not depressed.

32. New Beginnings Program (NBP) • Small group program for divorcing families • Emphases on learning new skills and applying them in the family

34. Effective Reading Instruction • If children cannot read competently by the third grade, they are very unlikely to ever become competent readers • Reading skill is required for academic success in every other subject • A number of effective reading instruction programs has been validated in randomized trials • These evidence-based approaches are often not used

35. Evidence-based kernels • Simple techniques for affecting behaviors • Easy to learn and use • Often quick results • More than fifty have been identified (Embry & Biglan, 2008)

36. Examples • Prize Bowl to reduce serious addictions and complete recovery goals • Beat the Timer • My Values activity to increase high school graduation • Goal Node Interview to decrease alcohol, tobacco and marijuana use, and/or increase prosocial goals • Omega 3 Supplementation • Praise notes

37. Effective Policies in the U.S. For all policies, we have applied the Standards of Evidence as defined by Flay et al. in the Standards of Evidence document , Prevention Science, 2005.

38. Effective Policies in the U.S. For all policies, we have applied the Standards of Evidence as defined by Flay et al. in the Standards of Evidence document , Prevention Science, 2005.

39. Talk Amongst Yourselves • What doubts, skepticism, and obstacles come to mind? • What might be a single specific step you might take to further prevention?

40. Poverty: The Most Important Risk Factor for Problem Development • School failure and drop out • Crime • Substance abuse • Depression • Poor self-regulation • Heart disease • Cancer

41. Among 25 Developed Countries, • The United States Has the Highest Proportion of Children Living in Poverty • And they are now higher than they have been since the 1960’s

42. Poverty Rates by Age: 1959 to 2002

43. So here’s the deal: • You, your spouse and two children get $22,162 a year. ($1846/ month or about $10 an hour) • What is your house payment? • Food? • Clothes? • Entertainment?

44. Poverty is associated with higher rates of • Mild mental retardation • School failure and drop out (Gutman et al., 2005) • Antisocial behavior (NICHD, 2005; Weatherburn & Lind, 2006) • Depression (Elder, Nguyen, & Caspi, 1985; Gutman et al., 2005) • Poor self-regulation (McLoyd, 1998)

45. Parenting: A key pathway from poverty to problem development • Parents under financial strain • Less involved with their children • More likely to criticize and argue with them (Gutman et al., 2005) • Such disrupted parenting contributes to children's • Anxiety and depression (Elder et al., 1985; Gutman et al., 1994) • Failure in school (Gutman et al., 1994) • Aggressive behavior (NICHD, 2001) • Delinquency (Weatherburn & Lind, 2006)

46. Health and Social Problems are Closely Related to Inequality in Rich Countries Worse * USA Portugal * Index of health and social problems UK * Greece * * New Zealand Ireland * Austria * France * Australia * Germany * * Canada Italy * Denmark * * Belgium * Spain Finland * * Netherlands * Switzerland Norway * * Sweden * Japan Better Income Inequality Low High

47. Death rates of working age men in Sweden vs. England and Wales Death rates among working-age men are lower in Sweden than in England and Wales, in all occupational classes

48. Rates of illness are lower at both high and low educational levels in England compared to the US Note: Within each grouping of three, lowest educational level is on the left and highest educational level is on the right

49. Policies: Poverty Reduction • Living wage ordinance • Uptake of benefits related to national and state assistance programs • Tenant-based rental assistance • Food assistance • Conditional cash transfers • Micro credit, micro finance • Enterprise zones • Health care access

50. ThePromiseNeighborhoods Initiative “It's a moral outrage that, in the richest nation on earth, 37 million Americans are living in poverty.” “I have called for the creation of a new program that replicates the success of the Harlem Children's Zone—an all-encompassing, all-hands-on-deck, anti-poverty effort that is literally saving a generation of children in a neighborhood where they were never supposed to have a chance.”