Current Best Practices in Prevention July 20, 2011

1. Current Best Practices in PreventionJuly 20, 2011 James Emshoff, Ph.D. Georgia State University EMSTAR Research, Inc.

2. Welcome July 20, 2011 We Will Be Starting Shortly

3. WELCOME! Charline McCord T/TA Coordinator Shannon Greer IT Specialist Iris E. Smith Coordinator Donna Dent Associate Coordinator CAPT Southeast Resource Team Penny Deavers T/TA Specialist, GRAA Carol A. Hagen Epidemiologist LaShawn Martin Sr. Admin Assistant Deirdre Danahar T/TA Specialist Bertha Gorham Evaluator Carlos Pavao T/TA Specialist

4. Welcome to Connect Pro • We will be using the following windows: • PowerPoint Window • Attendee List • Chat • Note • We will also use the “Raise your Hand” feature

5. Raise your hand by clicking You will see your status change in attendees list Un-mute your phone (press * #) when called upon Remember to mute your phone again once you have finished speaking Lower your hand by again clicking Introduction to Connect Pro

6. Asking Questions in Connect Pro • By Writing: • Write question in Chat window • Press enter • Only the moderator will see the question

7. Learning Objectives • By the end of this webinar, participants will be able to: • Describe current research and trends in prevention science • Describe processes, content, and principles to enhance the effectiveness of prevention programs. • Discuss examples of evidence-based prevention programs and practices that employ these processes, content and principles.

8. Rationale for Prevention • We believe in the logic – “a stitch in time…” “an ounce of prevention…” • If early initiation can be prevented, it is likely that lifetime addiction can be prevented. • The cost of alcohol and drug use in our society is $485 billion.

9. But It’s Still an Uphill Battle . . . • You can’t see what doesn’t happen • Costs now – benefits later • Crisis mentality • Political resistance

10. The Premise of Prevention Science To prevent a problem before it happens, the factors that predict the problem must be changed.

11. Two Major Advancesin Prevention Science • Identification of predictors of problem behaviors as targets for prevention • Identification of tested and effective preventive policies and programs

12. Principles

13. Promotive and Protective Factors • Individual Characteristics • High Intelligence • Resilient Temperament • Competencies and Skills

14. Promotive and Protective Factors • In social domains of family, school, peer group and neighborhood: • Pro-social opportunities • Reinforcement for pro-social involvement • Bonding (connectedness, attachment) • Clear and healthy standards for behavior

15. Promotive and Protective Factors (con’t.) • In social domains of family, school, peer group and neighborhood: • Opportunities for learning • Childcare • Good schools (i.e., high spending, good teachers, low student-teacher ratios, moderate size, supportive learning, small work units) • Health care • Most important when risk factors are high

16. Risk Factors forAdolescent Problem Behaviors Risk Factors Substance Abuse Delinquency Teen Pregnancy School Drop-Out Violence Depression &Anxiety Community Availability of Drugs X axe  Availability of Firearms    Community Laws and Norms Favorable Toward Drug Use, Firearms, and Crime   Media Portrayals of Violence  Transitions and Mobility     Low Neighborhood Attachment and Community Disorganization     Extreme Economic Deprivation    X 

17. School Risk Factors • Academic failure – beginning in late elementary school • Lack of commitment to school • Exposure to violence and drug use

18. Family Risk Factors • Family history • Family management problems • Family conflict – low family involvement • Favorable parental attitudes and low monitoring

19. Individual Risk Factors (Childhood) • Difficult temperament • Poor self-regulation • Sensation-seeking • Impulsive • Low harm avoidance • Anxiety • Depression • ADHD • ANY adverse childhood experiences or trauma (especially child maltreatment or family disruption)

20. Individual/Peer Risk Factors (Adolescence) • Deviant peers • Rejection by peers • Low commitment to school • School failure • Access and availability • Perceived norms • Negative emotions • Conduct disorder • Anti-social behavior

21. Individual Risk Factors (Young Adulthood) • College • Antisocial behavior • Lack of commitment to traditional adult roles

22. Underage Drinking • Risks start at ages 3-5, as children exposed to alcohol, norms, parental modeling, and associated positive expectancies • Later, role of peers increases • Prevention strategies: • Raising the drinking age • Raising prices • Limiting media and family exposure • Monitoring

23. One Risk Factor–Multiple Outcomes • Most substance abuse risk factors also predict: • Delinquency • Violence • School drop-out • Teen pregnancy • Depression and anxiety (more family, less community)

24. One Program – Multiple Outcomes • Preventive interventions that address shared risk factors for different adolescent health risk behaviors have produced reductions in multiple outcomes, including school dropout, drug use and crime. Hawkins et al, 1999; Botvin et al., 2002 ; Flay et al, 2004; Haggerty et al., 2007; Schweinhart et al, 1992; 2005

25. Risk and Protective Factor Models • Main effects – cumulative and direct • Moderating (e.g., the presence of a protective factor can moderate the effect of a risk factor; a genetic factor may exacerbate a risk factor) • Mediating – chains of events (e.g., poverty leads to ineffective parenting and/or living in disorganized neighborhoods which leads to problem behaviors)

26. How to Reduce Risk Factor Effects • Change the experience (e.g., teach coping) • Change exposure • Avert negative chain reactions • Increase protective factors • Change settings

27. Programs, Policies, and Practices

28. SAMHSA’s Strategic Prevention Framework

29. Preventive Intervention Opportunities

30. Prevention Programs • Universal programs reach the general population (such as all students in a school). • Selective programs target individuals or groups at elevated risk (such as children of drug users or poor school achievers). • Indicated programs focus on people who exhibit some symptoms of a disorder but not a diagnosable “case”. • Tiered programs incorporate two or more levels of intervention, with increasing intensity for individuals at greater risk.

31. School-Based Prevention • Schools are the most widely used setting for prevention • Schools provide access to children and adolescents • Programming should be developmentally appropriate • Effective programming has been identified at all grades

32. Effective School-Based Prevention • Is interactive • Focuses on social influences • Emphasizes norms and social commitment • Has a community component • Uses peer leaders • Uses life skills

33. Strategies that Do Not Work • Information only • Testimonials from recovered addicts • Scare tactics • Affective education (e.g., self-esteem building only) • Alternative programming (e.g., recreation programs without skills training)

34. Raising Healthy Children Core components • Teacher in-service training • Classroom management • Interactive teaching • Cooperative learning • Parent workshops • Raising healthy children – behavioral principles • Supporting school success • Guiding good choices, refusal and decision-making • Child social, cognitive and emotional skills training (e.g., problem solving, emotional regulation)

35. Outcomes • By the start of fifth grade, students exposed to full intervention reported: • less initiation of alcohol • less initiation of delinquency • better family management • better family communication

36. Outcomes (cont.) • By the start of fifth grade, students exposed to full intervention reported: • improved family involvement • higher attachment to family • higher school rewards • higher school bonding

37. Longer-Term OutcomesControls vs. Intervention Youth • By age 18: • Less heavy alcohol use (25% to 15%) • Less lifetime violence (60% to 48%) • Less grade repetition (23% to 14%) • By age 21: • More high school graduates (81% vs. 91%) • More attending college (6% vs. 14%) • Fewer selling drugs (13% vs. 4%) • Fewer with a criminal record (53% to 42%)

38. Effects on Sexually Transmitted Infection Onset through Age 30 Control 38.8% 26.2% Sig. effect on STI Hazard rate, p < 0.019 Tx Full Tx

39. $3.14 $1.00 Investment in Raising Healthy Children Reduces Costs of Later Problems Investment Return Aos et al. (2004)

40. Community and Environmental Change • Mass media campaigns are a part of the solution (Derzon et al, 2002) • Alcohol use reduced from 53% to 51% • Tobacco use reduced from 37% to 35% • Marijuana use reduced from 24% to 22% • Videos work best • Target parents • Include supplementary activities • More effective for males • Coalitions have promise

41. Community and Environmental Change • Restriction of outlet density and zoning • Enhanced enforcement of sales to minors • Limiting marketing, especially youth-oriented marketing

42. Community-Level Intervention • Communities Mobilizing for Change • Changed policies • Focused on alcohol outlets selling to youth • Reduced access from family and friends • Changed norms • Reduced access and teen • DUIs

43. Community-Level Intervention • Community Trials • Community mobilization • Responsible beverage service • Increased enforcement of drunk driving laws • Reduced underage access • Changed zoning and outlet access • EFFECTS: Reduced alcohol-related injuries and deaths

44. Safe Schools/Healthy Students (SS/HS) Initiative • Launched in 1999 as a comprehensive response to address the mental, emotional, and behavioral health of students and to make sure kids felt safe in their schools. • Represents an unprecedented collaboration between the U.S. Departments of Health and Human Services, Education, and Justice • Has served more than 365 grantees comprising schools and communities across the nation

45. Requires school districts to partner with their local mental health, juvenile justice, and law enforcement agencies Harnesses the power of schools, local agencies, and community partners to ensure that students: Feel safe in schools, free from violence and bullying Avoid drugs, alcohol, and violence Have increased access to mental health services Don’t feel isolated, because they can connect with their schools and communities SS/HS Goals

46. Schools and communities became safer and fewer students were exposed to violence A large number of school staff said they were better able to detect mental health issues in their students and also saw reductions in students’ alcohol and drug use Longstanding “silos” were broken down as schools began working closely with community agencies Findings

47. The SBIRT Concept • SBIRT uses a public health approach to universal screening for substance use problems. • SBIRT provides: • Immediate rule out of non-problem users; • Identification of levels of risk; • Identification of patients who would benefit from brief advise, and; • Identification of patients who would benefit from higher levels of care.

48. The Problem

49. Primary Goal • The primary goal of SBIRT is not to identify those who are dependent and need higher levels of care. • The primary goal of SBIRT is to identify those who are at moderate or high risk for psycho-social or health care problems related to their substance use choices.