“ w hat w orks, b est p ractices” by karol l. kumpfer, ph.d. director center for substance abuse...

““WWhat hat WWorks, orks,

BBest est PPractices”ractices”

By

Karol L. Kumpfer, Ph.D.Director

Center for Substance Abuse Prevention

2Substance Abuse and Mental Health Services Administration Center for Substance Abuse

Prevention


Prevention

Extent of the Drug Problem:

• Tobacco, alcohol, and drug abuse is a serious

health and social problem worldwide.

• Drug abuse has been increasing in the USA in adolescents since 1992. Last year drug abuse increased 27% in 12-17 year olds.

• Tobacco, alcohol, and drug abuse significantly contributes to rising health care costs and societal problems.

Substance Abuse Prevention:Substance Abuse Prevention:What Works!What Works!


Prevention

Good News: • We know how to prevent drug abuse by strengthening families, schools, and communities.

Bad News: • Prevention of drug abuse is not easy. There are no quick fixes. A media campaign is not enough.


Prevention

SUPPLY REDUCTION

• INTERDICTION

• CROP ERADICATION

• POLICY AND LAWS

• REDUCE ACCESS

• INCREASE COST

• SYSTEM CHANGE

• FAMILY

• SCHOOL

• COMMUNITY

INDIVIDUAL CHANGE PROGRAMS

• KNOWLEDGE

• ATTITUDE/NORMS

• SKILLS

AGENT/DRUG

ENVIRONMENT HOST/PERSON

Public Health Model TrianglePublic Health Model Triangle


Prevention

The Intervention Spectrum The Intervention Spectrum for Behavioral Disordersfor Behavioral Disorders

CaseIdentification Standard

Treatmentfor KnownDisorders

Compliancewith Long-TermTreatment(Goal: Reduction inRelapse and Recurrence)

Aftercare(Including

Rehabilitation)

Prev

entio

n

TreatmentM

aintenance

Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.

Indicated—Diagnosed Youth

Selective—Health RiskGroups

Universal—General Population


Prevention

Prevention: Three types of prevention interventions (Mrazek & Haggerty, IOM, 1994).

1. Universal (primary prevention with general population)

2. Selective (secondary prevention with high-risk groups, such as children of alcoholics, inner city youth, pregnant unmarried girls, etc.)

3. Indicated (secondary prevention with identified problem youth already manifesting a risk factor, i.e., school dropouts, delinquent youth, youth already smoking or drinking, etc.)


Prevention

U.S. Drug Abuse Prevention U.S. Drug Abuse Prevention Workshop ObjectivesWorkshop ObjectivesSession III:

Substance Abuse Prevention: What Works!

Purpose: • To give participants an understanding of effective

substance abuse prevention strategies


Prevention

The Need for Community The Need for Community CoalitionsCoalitions

• Community coalitions have become very popular for health promotion and disease prevention.

• The U.S. Center for Substance Abuse Prevention has initiated more than 250 community partnerships nationwide.

• Additional AOD community coalitions have been implemented by:

1. State and local governments

2. The Henry J. Kaiser Family Foundation


Prevention

The Need for Community The Need for Community Coalitions (cont.)Coalitions (cont.)

3. The Robert Wood Johnson Foundation’s “Fighting Back” coalitions

4. The National Cancer Institute's COMMIT and ASSIST tobacco and cancer reduction programs

5. The U.S. Centers for Disease Control and Prevention’s Planned Approach to Community Health (PATCH) health promotion program


Prevention

Annual Site Visits to 24 PartnershipsAnnual Site Visit Reports (N=24)Composite Reports (N=24)

1994-95 1996 Total

AdultsTenth gradersEighth graders

Total:

14,807 12,092 26,899 12,842 13,042 25,884 14,151 16,539 30,690 41,800 41,673 83,473

A Rigorous National EvaluationA Rigorous National EvaluationAge Groups Surveyed in the 24 Partnerships

and 24 Comparison Communities


Prevention

Adults are Less Likely to Use Illicit Drugs Adults are Less Likely to Use Illicit Drugs When:When: • Living in partnership communities,

• Participating in drug prevention activities,• Living in neighborhoods safe from drugs, and• Disapproving of drug use.

Less Likelihood ofIllicit Drug Use

•

In the Past Month

Involvement in Drug Prevention Activities

12

Vote for Issue B

639

12

•

SAMHSA-CSAP

Community Partnership

Neighborhood Perceived Safe From Drugs

DISAPPROVAL OF DRUGS

Red Ribbon Days


Prevention

Strong Core of Partners

Inclusive and Broad-based Membership

Reasonable Staff Turnover

Avoidance or Resolution of Severe Conflict

High Number of Prevention Contact Hours

Decentralized Units

Shared Vision

Comprehensive Vision

Outcome Evaluation Results:Outcome Evaluation Results:Characteristics of Successful Characteristics of Successful PartnershipsPartnerships


Prevention

A

dju

ste

d P

rev

ale

nc

e R

ate

s (

%)

Comparison CommunitiesPartnership Communities

Adults 10th Graders 8th Graders

p005*p036*t1 t2 t1 t2

p025*

11

12

0

6

7

8

9

10

t1 t2

0

20

22

24

26

28

30

32

0

20

22

24

26

28

*one-tailed

30 Day Illicit Drug Use30 Day Illicit Drug UseMALESMALES


Prevention

Ad

just

ed P

reva

len

ce R

ates

(%

) Adults 10th Graders 8th Graders

Comparison CommunitiesPartnership Communities

28

0p030*t1 t2

60

62

64

66

0t1 t2

44

46

48

0 p005*

t1 t2

26

30

32

34

*one-tailed

30 Day Alcohol Use30 Day Alcohol UseMALESMALES


Prevention

Four Steps for Choosing a Four Steps for Choosing a Research-based Prevention Research-based Prevention ProgramProgramStep 1: Read Reviews of the Research Literature

• Psychology Bulletin article (Hawkins, Catalano, & Miller (1992), • Communities That Care (Hawkins, et al., 1993), • The Making of a Drug-Free America (Falco, 1993). • Drug Abuse Prevention in Multi-ethnic Youth (Botvin, Schinke, and Orlandi, 1995).


Prevention

Four Steps for Choosing a Four Steps for Choosing a Research-based Prevention Research-based Prevention Program (Continued)Program (Continued)

Step 2: Gather Local Data

Step 3: Determine Why These High-Risk Individuals Use Drugs

Step 4: Select the Best Prevention Intervention


Prevention

Step 4.1: Where in the Prevention Continuum to Intervene?

First you should decide where in the Prevention Possibilities Frontier or risk continuum you want to intervene:

1. Before there are any risk indicators with general population using universal approaches,

2. Using selective approaches for high-risk groups, or

3. Using indicated approaches for individuals already using or manifesting symptoms of use (dropping grades, isolation, and antisocial behavior).


Prevention

Step 4.2: Which Sites to Focus Upon—School, Family, Community?

Step 4.3: Choosing the Most Effective Approach


Prevention

Peer-focused Prevention Peer-focused Prevention ApproachesApproachesFinal pathway to Drug Use= Peer Norms and Pressure

Effective Approaches

1. Peer Resistance Training2. Normative Education.

Resistance to peer pressure can be increased through involvement in peer resistance training programs which have been shown to delay initiation of drug use (Dielman, Shope, Leech, & Butchart, 1989; Pentz, et al., 1989).


Prevention

Prevention MatrixPrevention MatrixThe following table provides an overview of Universal, Selective, and Indicated as defined by school-based approaches, family focused approaches, and community based approaches.

Universal Selective Indicated

Targeted Individuals at High Risk

I. InformationII. Education curriculums • social inoculation • peer resistance • normative education • life skill trainingIII. School climate change programs • school policies • instructional changesIV. School coalitions • multiple approaches

I. Alternative Programs • youth skills training • after school or special class/club • sports or recreationII. Cultural pride & competencyIII. Peer leadershipIV. TutoringV. MentoringVI. Children of Alcoholics GroupsVII. Trauma & Violence PreventionVIII. Parent-peer groups

• alternatives programs • peer leadership • peer counseling • tutoring • mentoring • cultural pride • in-school suspension • student assistance • student crisis line & warm lines • school support group • aftercare group • alternative schools/classes

School-based approaches

General population (mixed low, high risk)

Targeted Population at High risks


Prevention

Prevention Matrix (Continued)Prevention Matrix (Continued)

• parent education - groups - lectures -curriculums • parent support • parent skills training (1-7 sessions) • family skills training (1-7 sessions)

• home visits • parent skills training (10+ sessions) • family skills training (7+ sessions) • family case/ manager • parent support groups

• family skills training • parent-peer group for troubled youth • parent self-help support group • tough love • family treatment - structural - strategic - functional • family services

Family-focused approaches

Community-based approaches

• public awareness • community mobilization • community coalitions/task forces • school/community partnerships • church sponsored youth groups

• youth clubs • recreation • outdoor challenges • mentoring • tutoring • school homework support • community partners (inner city, housing projects)

• rites of passage programs• gang & delinquency prevention• alternative programs• job skill training• job apprentice programs

Universal Selective Indicated


Prevention

Strengthening Schools, Families Strengthening Schools, Families and Communities Approaches and Communities Approaches

1.Information Prevention Approaches

Programs employing this strategy provide awareness and knowledge of:

• Pharmacological effects of drugs • Health, psychological and social

consequences of abuse • School and community attitudes, norms,

legal sanctions, and sanctions • General health education.


Prevention

Results

1. Increase students' knowledge about drugs 2. Impact on decreasing or delaying use is not known because most information programs do not measure behavioral objectives (Moskowitz, 1983)

1.1.Information Prevention ApproachesInformation Prevention Approaches.. (Continued) (Continued)


Prevention

• Information-only approaches to prevention have been criticized on the following grounds:

1. Knowledge Alone May Not Change Behavior 2. Youth most at-risk for drug use are school drop-outs 3. The information source often not considered credible by youth 4. Most educational programs too short to produce behavior changes 5. Often drug information is not specifically designed to match the appropriate local cultural and ethnic traditions


Prevention

• Information about consequences may deter low-risk youth from drug initiation, particularly with highly addictive drugs or drugs with well accepted negative effects (e.g., designer drugs)

• Information is helpful to those living with drug users or to those wanting to know how to identify symptoms of drug use, intervention methods, and referral sources


Prevention

2. Prevention Education and Skills Training Programs

• More intensive (more hours per person) than information dissemination programs

• Cost more per participant

Strengthening Schools, Families Strengthening Schools, Families and Communities Approachesand Communities Approaches(Continued) (Continued)


Prevention

2. Prevention Education and Skills Training Programs (Continued)

Examples

• Life skills training• Peer and media resistance training• Classroom or small group sessions• Peer leader/helper programs• Children of substance abuse groups• Parenting and family skills training

classes

• Youth or adult involvement in design and implementation helps (National Assembly, 1994)


Prevention

The skills training or social competency approaches behaviorally train students to resist pressures to use drugs and to learn social skills through three different strategies:

1) The Social Influences Approach involving media persuasion resistance training and peer resistance social skills training, used in Project STAR, and I-STAR in the Midwestern Prevention Project (Pentz 1983; Pentz, et al., 1989) and the DARE program


Prevention

2. The Normative Education Approach which encourages adoption of norms against drug use and corrects inflated estimates found in youth about the number of youth who actually use drugs (Hansen, 1992; Hansen & Graham, 1991)

3. The Life Skills or Social Skills Approach (Botvin and associates., 1990 (a,b,c)) teach youth how to communicate, control stress and feelings of anger or anxiety, restore self-concept, choose prosocial friends, increase social status, and resist media and peer pressure to use drugs


Prevention

Intervention methods

1. Demonstrations of effective and ineffective behaviors 2. Trainer demonstrations 3. Participant role plays with feedback

4. Reinforcement for changed behavior 5. Role Modeling

6. Positive peer group norms


Prevention

Results

Modest reductions in onset and prevalence of cigarette smoking, alcohol, and marijuana use if:

• Interactive classes better than lectures• Peer led classes better than teacher-led classes• Some negative effects in students who were already using


Prevention

2. Alternative Programs Including recreational, sports, cultural, and educational activities

• Used with high-risk individuals because of the increased cost

• The theoretical justification is that providing individuals with "alternative highs” incompatible with substance use will reduce use.



Prevention

2. Alternative Programs (Continued)

• Also, some research supports a link between sensation or thrill seeking personality and drug use

Types

• Experiential Education Programs involving wilderness experiences, ropes courses, mountain climbing, rapelling, and rafting.

• Community Service Programs (removing graffiti or developing community murals), building homes, and volunteering to help others (Tobler, 1986)


Prevention

2. Alternative Programs (Continued)

Examples

1. Amazing Alternatives was developed by Murray and Perry (1985).2. CSAP High-risk Youth Grants with experiential education programs

Results

• Effectiveness Unclear (Schaps and associates (1981)


Prevention

Results (Continued)

• Some alternative activities (academic, religious, and active hobbies) decrease use and others (entertainment, sports, social, extracurricular, and vocational activities) promote increased use

• Critical ingredient is who youth associate with in the activities


Prevention

4. Intervention Approaches

• Indicated prevention programs for drug users or individuals showing mental health symptoms of risk (e.g., delinquency, aggression, depression, and other anti-social behavior)

• Strategies involve problem identification, screening and referrals to special therapeutic programs



Prevention

4. Intervention Approaches (Continued)

Examples:

• Student assistance programs (Morehouse, 1979)• Peer counseling programs• Parent-peer groups for troubled youth• Teen hot lines and crisis intervention (Tobler, 1986, 1992)


Prevention

Community Based PreventionCommunity Based PreventionInterventionsInterventions1. Public Awareness and Media Campaigns

Results

• Media campaigns do affect the community's social norms when combined with other community prevention strategies (Wallach, 1985)

• In addition, the public demand for credible information about drugs is increasing and

should be satisfied by accurate and scientifically credible messages


Prevention

1. Public Awareness and Media Campaigns. (Continued)

Examples

• The Partnership for A Drug-free America (1994) reports producing more than 400 anti-drug ads for their national campaign worth $1.8 billion in media donations.

They were recently awarded advertising's most prestigious award for effectiveness—

the Grand Effie


Prevention

2. Youth Development Services.

Implemented in community agencies serving high-risk youth with the purpose of generally improving youth development and outcomes. Many of these selective or indicated prevention programs are funded with CSAP or local county or state funds from State Block Grant or state legislative appropriations.

Community Based PreventionCommunity Based PreventionInterventions (Continued)Interventions (Continued)


Prevention

3. Social Interaction Skills Training Approaches:

• The Botvin’s Life Skills Training Program: a drug prevention curriculum implemented in Philadelphia alternative Scholls was found to increase knowledge about tobacco and alcohol use, negative attitudes toward marijuana use, and decrease school problems, incidents of drunker aggression, and legal problems.



Prevention

3. Social Interaction Skills Training Approaches: (Continued)

• The Smart Moves Program: a drug prevention curriculum based on the original pear resistance skills training program was implemented in public housing projects by Boys and Girls Clubs. Studies showed

that the presence of crack was lower in developments served by Clubs with Smart

Moves (Schinke, Orlandi, and Cole 1992


Prevention

4. Mentoring Programs:

Convey positive values, attitudes and life skills through a one-to-one relationship with a positive role model, who may be a culturally matched community volunteer, college student, parent, or business professional, or retired person. Becoming very popular, currently this

approach is not as frequently used (found in 14% of the first 75 CSAP high-risk youth grants), except as part of a more comprehensive program



Prevention

5. Tutoring Programs:

Tutoring programs reduce academic problems by improving academic achievement. Tutors can be mentors, college students, grandparents, professionals, or teachers to tutor students in school or after school.



Prevention

6. Rites of Passage Programs:

These programs focus on:

1. Responsibility training, skills training, resiliency, community bonding, and spiritual values



Prevention

6. Rites of Passage Programs (Continued)

Example:

The Comprehensive Afro-American Adolescent Services Project operated by the University of Cincinnati included twenty 2-hour rites of passage discussion groups with community action projects and entrepreneurial training


Prevention

Critical Role of FamiliesCritical Role of Families• The family is the social unit primarily responsible for

child rearing functions.

• When families fail to fulfill this responsibility, the entire society suffers.

• Families are responsible for providing:

– Physical necessities

– Emotional support

– Learning opportunities

– Moral guidance

– Building self-esteem and resilience


Prevention


Prevention

CSAP Family PEPS (1998)CSAP Family PEPS (1998)

Effective Family Intervention Strategies 1. Parent training

2. Family skills training

3. Family in-home support

4. Family therapy


Prevention

Principles of EffectivePrinciples of EffectiveFamily-Focused ProgramsFamily-Focused Programs1. There Is No One Best Family-Focused Program.

• Select Programs Based On:– Ages of Children– Cultural Appropriateness– General Level of Family Needs (Universal Low Risk Families)

• Specific Family Needs. Different Types of Family Interventions Are Used to Modify Different Risk and Protective Factors.


Prevention

Strengthening America’s FamiliesStrengthening America’s FamiliesProgram MatrixProgram Matrix

HIPPY — New York, NY

MELD — Mineapolis, MN

First Step — Cannon, City, Co

Birth to Three — Eugene, OR

Health Start — St. Paul Minnesota

I Can Problem Solve Philadelphia, PA

Healthy Families America/Indiana Indianapolis, IN

Prenatal and Early Childhood Nurse Home Visitation Program Denver, CO

CEDEN Healthy and Fair Start Austin, TX

Preparing for the Drug Free Years — Seattle, WA

Strengthening Families Program Salt Lake City, UT

Video-Based Parenting — Seattle, WA

Strengthening Hawaii Families Honolulu, HI

Helping the Noncompliant ChildSeattle, WA

Focus on Families Seattle, WA

Iowa Strengthening Families Program Ames, IA

FASTMadison, WI

Families in FocusSalt Lake City, UT

Family Support ProgramRocky Mountain, VA

Multisystemic Family TherapyCharleston,SC

Functional Family TherapySalt Lake City, UT

Home-Based FFT — Athens, OH

Structural Family Therapy — Miami, FL

Treatment Foster Care — Eugene, OR

Parents AnonymousCompton, CA

Parent ProjectRound Lake, IL

Nurturing Program Park City, UT

Strengthening Multi-Ethnic Families and Communities Los Angeles, CA

Effective Black ParentingStudio City, CA

Project Seek — Lansing, MI

HOMEBUILDERS — Federal Way, WA

Parenting Adolescents Wisely Athens, OH

Bethesda Day Treatment — Milton, PA

Coordinated Children’s Services Huntington, NY

0-5

(age)

6-10

(age)

11-18

(age)

0-18

(age)

Universal (General Population)

Selected(High-Risk Population)

Indicated(In-Crisis Population)


Prevention

Thirty-four Effective family intervention programs can be found on web site

www-medlib.med.utah.edu/healthed/ojjdp.htm

or call (801) 581-7718 at the University of Utah Health Education Department

“ w hat w orks, b est p ractices” by karol l. kumpfer, ph.d. director center for substance abuse...

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prevention of drug abuse

year drug abuse

disease prevention

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health promotion

mental disorders