Innovations in Prevention: Youth Substance Abuse & Dating ViolenceChristine Wekerle, Ph.D. The University of Western Ontario cwekerle@uwo.ca

Violence in intimate relationships can be onein which great intensity of positive longing, anger, and fear may be combined with a lack of felt security, lapses in attention, dysfluent communication, and unregulated arousal. (Lyons-Ruth & Jacobvitz, 1999)

Similar Examples: Different OutcomesDevelopmental context relationshipsPerhaps type of relationship - attachmentTopographically similar eventsFunctionally similar behaviours to a pointAffectively similar to a pointGood cognitive awareness of eventHow to change? Motivation to change?Would change or self-correction occur on its own?

Natural Reduction ProcessesTeens who stop drinking (DAmico et al., 2001; Brown, 2001)Independent Effort (willpower, forced myself)Structured Activity (sports, hobbies, church)Social Support (family, new friends)High school binge-drinkers who refrained from binging (past 3 months) in college did not differ in drinking milestones or severity of substance use from current bingers Natural reducers in college were, on average, 3 years older, more likely to be married, regular church go-ers, greater belief in ability to resist social pressure to drink, less ambivalence about changing drinking, and expected alcohol to enhance their personal experiences less

(Vik et al., 2003)

Change in peer group and greater parental engagement support youth in reducing their drinking (Stice et al., 1998)

Universal PreventionInterventions that target the whole population that has not been identified on the basis of individual risk Goal = to decrease the number of new cases (decrease incidence of disorders)

52% of youth have no risk behaviors (OSDUS, 2003)A minority of high school youth may volunteer for intervention on drinking prevention (e.g., 10% of 4500 students in 3 schools, DAmico et al., 2001)

Query: How to reach more youth? (e.g., building into school curriculum; use medical settings)

Many ER injury presentation involve substance use (e.g. motor vehicle accident) with youth showing initial heightened affect, long ER wait can be capitalized to create a teachable moment eliciting ambivalence from teens about their alcohol use and promote interest in reducing dangerous drinking

LST gr. 7, 15-17 classes (45 minutes) middle or junior high school; 10 booster sessions in gr. 8; 5 booster sessions in gr.9 (some aspects of dating skills related to dating relationships); Teachers Manual and Student Guide (Princeton Health Press) (facilitated by regular classroom teacher, older peer leader, outside health care professional); effective for smoking, alcohol, marijuana, illicit drugs, beginning to examine aggressive and violent behavior e.g. program effects emerged at 6 mo. follow-up for reduced heavy drinking, recent drinking, getting drunk within RCT. Program effects observed at 6 year follow-up. Tested with Hispanic, African-American youth.

Gilbert J. Botvin, Institute for Prevention Research, Cornell University Medical College, NY most extensively evaluated substance abuse, school-based prevention, with over 15 years of research

Selected PreventionInterventions that target individuals or sub-groups with at-risk status Goal= to lower the number of established cases (decrease prevalence of disorder)

20% of children/youth experience past year mental disorder symptoms and 75-80% of these fail to receive services (USDHHS, 1999)28% of youth report 1 problem behaviour10% of youth report 3-4 problems

(OSDUS, 2003)

You can also have a layering strategy where you test the effects of a selected prevention for high-risk youth with and without also receiving a universal prevention (Coping Power program, Lochman, Wells, & Murray targeting aggression) where you can consider the potential added benefit to the high-risk youth and the benefit to the wider population (Tolan & Goran-Smith, 2002)

Key Windows of Opportunities

Perinatal and Early Childhood Programs targeting parents, infants, young children

Education Programs targeting school-age children and teens

Distal Factor: Child MaltreatmentEffective parenting is the most powerful way to reduce youth problem behaviours (Kumpfer & Alvarado, 2003)

Child maltreatment may be the single most preventable and intervenable contributor to child and adult mental illness (DeBellis, 2003)

Violence victimization is associated with a lower age of drinking initiation (Nagy & Dunn, 1999)

You know the only people who are always sure about the proper way to raise children? Those whove never had any. Bill Cosby

Substance-Abusing Caregivers Reported to Child WelfarePoverty (income < $15,000, OR=1.6)Multiple moves in the past 6 months (3+, OR=5.2)Unsafe housing (OR=1.9)Minority racial status (Aboriginal OR=3.4; Other Minority OR=1.4)Low caregiver education (OR=1.9)Criminal activity (OR=4.8)Involvement in a violent relationship (OR=3.8)History of childhood maltreatment (OR=3.2)Mental (OR=2.8) and physical (OR=2.6) health issues Lack of social supports (OR=2.6)

table 1&2

Table 1Table 2

Substance abuse and Caregivers' FunctioningSubstance abuse and Household Characteristics

Substance Abuse StatusSubstance Abuse Status

OR(95% CI)OR(95% CI)

Mental Health Issue2.79 (2.33, 3.35)**Family Structure

Physical Health2.63 (2.13, 3.25)**Biological parent & others1.38 (1.16, 1.64)**

Criminal4.77 (3.90, 5.84)**Lone male caregiver1.36 (1.04, 1.78)*

Histroy of Violent Relationship3.74 (3.28, 4.28)**Other structure0.65 (0.44, 0.97)*

Histroy of Maltreatment3.16 (2.78, 3.60)**Houehold education0.54 (0.47, 0.64)**

Lacks Social Support2.57 (2.21, 3.00)**Family Income0.76 (0.70, 0.81)**

Accommodation Arrangement

OR=odds ratio; CI=confidence interval

** p

Child Maltreatment & PreventionLack of adoption of evidenced-based parenting programs by community agencies (Kumpfer & Alvarado, 2003)

Child welfare youth important, but under-attended subpopulation for prevention

Need to show change in child abuse rates due to prevention parallel change in adolescent risk behavior rates in same community/population

Assessing Impact: Community Report CardUseful tool for impact evaluation Create a relevant surveillance system beyond problem behavior rates

e.g., percentage of schools with prevention programs; youth recreation space; rate of youth unemployment, per capita spending on support services

Link data bases that track health services utilization with community child abuse reporting rates, educational testing outcomes

see Strike, C., Goering, P., & Waslylenki, D. (2002). A population health framework for inner-city mental health. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 79, S13-S20.

Effective Prevention: What You Need To Know & WhyBaserates of problem behaviour Outcome Targets Inter-relationships of behaviours Multiple TargetsDevelopmental trajectories Developmentally-timed intervention Explanatory factors: Mediators Change TargetsContextual factors: Moderators Matching to sub- groups

Robust risk factors males motivation for substance use to get drunk

Baserates are a characteristics of a population, epidemiological (population-based sampling) needed to garner baserates rather than selection of studiese.g., factors that yielded a high proportion of true positives to false positives for marijuana users include family characteristics, mixed drug use, prior marijuana use (want to capture likely users)Factors yielding a larger proportion of true positives to false positives (want to maximize users) drug attitudes and prior intentions was the best predictorDerzon, J., & Lipsey, MW (1999). What good predictors of marijuana use are good for: A synthesis of research. School Psychology International, 20, 69-85.

Baserates: Youth Substance Abuse & Dating Violence21% males; 17% females report hazardous drinking24% report drunkenness past month26% binge drink past month10%, 2-3 binge episodes/month8% weekly; 4% daily marijuana use (OSDUS, CAMH, 2003)8.9% physically assaulted in dating relationship past year11.9% females; 6.1% males ever forced into sexual intercourse (YRBSS, CDC, 2003)19% emotional abused (ADDHealth, Carver et al., 2003)

Points for Developmental TimingDevelopmental Tasks:Emotional Autonomy Behavioural IndependenceIdentity Sexuality & Romantic RelationshipsSchool Achievement & Career Planning

Stages of Change (Transtheoretical Model of Change; Prochaska, DiClemente, & Norcross, 1992)

Prevention Possibilities

Precontemplation = no problem identification and/or has no intention of changingContemplation = problem identification but no action planPreparation = problem identification, motivation or readiness for change, early action stepsAction = demonstrated behavior change; early maintenanceMaintenance = maintained behavior change over time

Stages of Change

Stages of Change

Im not interested in changing.

Im where I want to be!

Im sticking with changes.

Im making changes.

Im getting ready to change.

Im thinking about changing.

6.

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4.

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Im slipping.

2.

1.

3.

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5.

In this last session, clients are introduced to the stages of change and made aware of the process of change. Changes made during First Contact are reinforced, by having clients identify where they were initially compared to where they are now. In addition, clients engage in planning for getting to the next stage and identify what might be useful for them in the future.

Change Targets: MotivationMotivational Interviewing= Client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence (Miller & Rollnick, 2002)Motivation regarded as a state not traitNon-hard confrontational yet directiveResponsibility for change rests with youthHighlights the need to consider motivation explicitly as a target in prevention programming

Motivation for what specifically? Pre-use: motivation to abstain or delay use Once engaged: to refuse, to avoid, to reduce, to do healthier alternative

Motivational Interviewing Key Tool:Decisional BalancingDevelop Ambivalence about UseTailored to stage-of-changeDiscrepancy=motivationDiscussion on pros and cons of use (likes/dislikes)Providing normative feedbackImagine future if behavior stay same or were to change (future goals)Help client identify and clarify their own goals and values so that discrepancy is related to what is important to the teenTeen presents the reasons for change

Open-ended questions encourage teens to generate all their likes and dislikes about the behavior (drinking, being aggressive with partner) and to talk about the effects of the behavior that matters most to them (e.g., whats the worst thing that they could imagining happening)What do you like? Dislike? Most important thing? Worst thing?So although drinking beer helps you relax and enjoy yourself, it also can make you do things that you wish you hadntSo although swearing gets you partners attention, it also makes you feel like you havent really respected herIf you decided to change, what do youth think would become easier in your life?What is the teen willing to do next..Where does this leave you now?On a scale of 1-10, how interested are you in____? What do you think would have to happen to increase that number?

Change Targets: Pattern of ReinforcersBehavioral Choice Theory: Draws attention to the relative reinforcement attained from behavior within the context of other reinforcers that predicts substance use/aggression (preference, Vuchinich, 1995)

Factors that influence consumer behavior:Direct constraints on access to the reinforcer (e.g., if dating partner leaves when threatens aggression; cant acquire alcohol due to being under legal age of drinking)Availability of alternative reinforcers and constraints on access to them (e.g., talk to friend about conflict and friend is readily available; exercise instead of use alcohol with highly valued exercise readily available)

Reinforcers for refusing to use substances or aggression greater than for engaging in behavior

Mediators: PTSD SymptomatologyDSM- IV Symptom Classes:Re-experiencing: recurrent, intrusive thoughts; bad dreams*; sense of re-living*; physiological reactivity and psychological distress* at cue exposure(2) Avoidance/Numbing*: avoid thoughts, feelings, places, people, activities related to trauma*; gaps in recall; feeling detached; feeling problems; pessimism about future(3) Arousal: sleeping, anger, irritability, startle*, hypervigilance, concentration difficulty

* Higher among chronic, abused youth (Fletcher, 2003)

Cross-lagged Structural Model Of Trauma Symptoms As A Predictor Of Child Maltreatment And Dating Violence For Boys, Adjusted To Include Independent Mediator Paths For Emotional Abuse

Time 1

Time 2

.62**

Trauma

Symptoms

Trauma

Symptoms

.32**

.23**

.41**

.38**

Child Mal-treatment

Emotional Abuse

Emotional Abuse

.25**

Dating Violence

Dating Violence

.25**

Cross-lagged Structural Model Of Trauma Symptoms As A Predictor Of Child Maltreatment And Dating Violence For Girls, Adjusted To Include Independent Mediator Paths For Anger

Time 1

Time 2

.75**

Trauma

Symptoms

Trauma

Symptoms

.52**

Anger

Anger

Child Mal-treatment

.23**

.25**

.22*

.19**

.16*

.20**

Dating

Violence

Dating Violence

.58**

TSCC anger subscale getting mad and cant calm down

Dating Violence Prevention:The Youth Relationships Project Rationale: Youth with a child maltreatment history at greater risk for relationship violence Target Age: Mid-adolescence (age 14-17) [By age 14, 55% had romantic relationship; by 17, 80% had romantic relationship, Carver et al., 2003]Targets: (1) concept of relationships(2) relationships skills(3) social action (mastery via advocacy)Program: 18 sessions (2-hr) coeducational group format, coeducational facilitation semi-structured manual

Results: Reduced dating violence involvement, Reduced PTSD symptomatology within a RCT design with child welfare youth(Wolfe, Wekerle et al., 2003)

The YRP may benefit from a motivational interviewing component readiness to change, with personalized feedback

Youth Prevention Information Sources (see American Psychologist, 2003, vol. 58)Lists of Effective Prevention Programs:Center for Substance Abuse Prevention Centers for Disease Control and PreventionNational Institute on Drug AbuseUS Department of Education Office of Safe and Drug-Free SchoolsSurgeon Generals OfficeOffice of Juvenile Justice and Delinquency Prevention

ConclusionsNeed to consider utility of dual or multi-targeting targets for prevention based on demonstrated co-morbidities

Need for broader surveillance on dating violence behaviorsNeed for teen violence prevention to consider applicability of effective substance abuse prevention components e.g., motivational interviewing, beliefs about/motives for aggression Need for substance abuse prevention to consider issues stemming from violence work, such as child maltreatment history, PTSDNeed to understand better SES, gender, ethnicity/culture as moderators of outcome and adaptation to important subgroups e.g., child welfare youthNeed to demonstrate efficacious prevention through population surveillance

Community report card would

Change in peer group and greater parental engagement support youth in reducing their drinking (Stice et al., 1998)Many ER injury presentation involve substance use (e.g. motor vehicle accident) with youth showing initial heightened affect, long ER wait can be capitalized to create a teachable moment eliciting ambivalence from teens about their alcohol use and promote interest in reducing dangerous drinking

LST gr. 7, 15-17 classes (45 minutes) middle or junior high school; 10 booster sessions in gr. 8; 5 booster sessions in gr.9 (some aspects of dating skills related to dating relationships); Teachers Manual and Student Guide (Princeton Health Press) (facilitated by regular classroom teacher, older peer leader, outside health care professional); effective for smoking, alcohol, marijuana, illicit drugs, beginning to examine aggressive and violent behavior e.g. program effects emerged at 6 mo. follow-up for reduced heavy drinking, recent drinking, getting drunk within RCT. Program effects observed at 6 year follow-up. Tested with Hispanic, African-American youth.

Gilbert J. Botvin, Institute for Prevention Research, Cornell University Medical College, NY most extensively evaluated substance abuse, school-based prevention, with over 15 years of researchYou can also have a layering strategy where you test the effects of a selected prevention for high-risk youth with and without also receiving a universal prevention (Coping Power program, Lochman, Wells, & Murray targeting aggression) where you can consider the potential added benefit to the high-risk youth and the benefit to the wider population (Tolan & Goran-Smith, 2002)Robust risk factors males motivation for substance use to get drunk

Baserates are a characteristics of a population, epidemiological (population-based sampling) needed to garner baserates rather than selection of studiese.g., factors that yielded a high proportion of true positives to false positives for marijuana users include family characteristics, mixed drug use, prior marijuana use (want to capture likely users)Factors yielding a larger proportion of true positives to false positives (want to maximize users) drug attitudes and prior intentions was the best predictorDerzon, J., & Lipsey, MW (1999). What good predictors of marijuana use are good for: A synthesis of research. School Psychology International, 20, 69-85.Precontemplation = no problem identification and/or has no intention of changingContemplation = problem identification but no action planPreparation = problem identification, motivation or readiness for change, early action stepsAction = demonstrated behavior change; early maintenanceMaintenance = maintained behavior change over timeIn this last session, clients are introduced to the stages of change and made aware of the process of change. Changes made during First Contact are reinforced, by having clients identify where they were initially compared to where they are now. In addition, clients engage in planning for getting to the next stage and identify what might be useful for them in the future.Open-ended questions encourage teens to generate all their likes and dislikes about the behavior (drinking, being aggressive with partner) and to talk about the effects of the behavior that matters most to them (e.g., whats the worst thing that they could imagining happening)What do you like? Dislike? Most important thing? Worst thing?So although drinking beer helps you relax and enjoy yourself, it also can make you do things that you wish you hadntSo although swearing gets you partners attention, it also makes you feel like you havent really respected herIf you decided to change, what do youth think would become easier in your life?What is the teen willing to do next..Where does this leave you now?On a scale of 1-10, how interested are you in____? What do you think would have to happen to increase that number?Reinforcers for refusing to use substances or aggression greater than for engaging in behaviorTSCC anger subscale getting mad and cant calm downThe YRP may benefit from a motivational interviewing component readiness to change, with personalized feedbackCommunity report card would