Early
Intervention:
One
of Seven Science-Based Prevention Strategies
WHAT
WORKS IN PREVENTION?
Researchers
at the national level are making great strides toward answering
this important question. In recent years, they have distilled
effective strategies and principles from the many programs that
seek to prevent and reduce substance abuse. Now, across the country,
more and more practitioners are coming to understand how critical
it is to identify and use science-based strategies that are likely
to be effective in meeting the needs of the people they serve.
For
the Center for Substance Abuse Prevention (CSAP), Gardner and
Brounstein have identified principles of effective substance abuse
prevention.1
From
these, CSAP’s Northeast CAPT has specified seven effective
prevention approaches. (See chart before endnotes.) They are:
- Policy
- Enforcement
- Collaboration
- Communications
- Education
- Early
Intervention
- Alternatives
Early
intervention strategies are more likely to be effective if they:
- Are
targeted to families considered at-risk for or who are already
using alcohol, tobacco, and other drugs
- Include
skill-building activities for both parents and children
- Identify
and build on the strengths of the family
- Offer
incentives for participation
- Are
culturally appropriate
- Address
the relationship between substance abuse and other health issues
As
communities around the country are learning, the key to effective
prevention is to use multiple strategies, in multiple settings,
toward one common goal. Communities should examine their local
situations, identify their specific needs, and look for ways to
combine seven strategies that have proven effective: policy, enforcement,
collaboration, communications, education, early intervention,
and alternatives.
Multiple
strategies, in multiple settings, toward one common goal.
WHAT
IS EARLY INTERVENTION?
Early
Intervention is a prevention strategy targeted at individuals
and groups at risk of developing substance abuse problems. It
focuses on youth who, because of their family situation, individual
characteristics, or environment, have risk factors known to be
correlated with alcohol, tobacco, and other drug use. Because
early intervention is more intensive and specialized than, say,
educational campaigns about the dangers of drug abuse, it is not
used for large populations of people.
Early
intervention to prevent substance abuse includes those interventions
that:
- work
with children at risk for abusing substances in the future,
either because of family risk factors, environmental risk factors,
individual risk factors, or early childhood behavioral indicator
- work
with young people who have just begun to abuse substances but
before the problem becomes more pervasive or entrenched
- work
with families, including mothers pregnant with their first child,
whose home environment or parental behavior increases the likelihood
of youth substance abuse
Thus,
the term "early intervention" refers not only to prenatal
and early childhood interventions, that is, "early"
in a child’s life, but also to those strategies that work
with young people of all ages who are just beginning to exhibit
serious behavioral problems, including substance abuse.
Early
intervention can, therefore, be the nexus between prevention and
treatment. It is considered a preventive strategy in that it reduces
the likelihood that young people will begin to use substances
or become dependent on them in the future. Its goal is to improve
children’s protective factors and reduce their risk factors,
using strategies targeted to each child’s developmental stage
and level of risk.
In
determining the most effective strategies for promoting health
within a given population, practitioners benefit from the Institute
of Medicine’s classification system, in which interventions
are deemed to be universal, selective, or indicated.
Universal interventions target an entire population, regardless
of risk status. Selective interventions focus on groups at higher
risk. Indicated strategies target individuals who have already
demonstrated to be at greatest risk of a behavior, condition,
or outcome. Early intervention generally focuses on the latter
two categories where there is sufficient risk to warrant a more
structured, targeted prevention strategy.
Early
intervention to reduce youth substance abuse can include a broad
range of strategies:
- Screening
and assessment to identify behaviors that put individuals
at risk and help develop a targeted intervention
- Support
services for families in crisis, such as economic assistance,
counseling, and therapy to meet basic needs for food, shelter,
and health care
- Home
visitation programs to support new parents, build skills
in child care and parenting techniques, and help adults further
their own education or job-training plans
- Early
education to build social skills, cognitive capabilities,
and self-esteem necessary to resist peer pressure to use alcohol,
tobacco, and other drugs
- Family
skills training that combines parent training, child skill-building,
and family behavioral therapy to create a comprehensive intervention
that engages all members of the family
- Student
assistance programs to provide counseling for young people
who have already shown signs of potential drug and alcohol involvement
- Family
therapy for families in which family members (including
youth) are using substances and are also at risk of other behavioral
problems
- Systemic
interventions that address multiple domains in a young person’s
life: individual characteristics, home environment, family interactions,
peer relationships, and neighborhood and community influences
Many
of the early intervention programs described in this paper combine
two of more of these strategies.
BENEFITS
OF EARLY INTERVENTION
The
most obvious—and desired—benefit of early intervention
is reducing the likelihood that high-risk individuals will become
dependent upon alcohol, tobacco, or other drugs. The research
on the strategies discussed in this paper shows that, indeed,
prevention can work. Treatment programs for adolescent and adult
substance abuse, while demonstrated to be effective in stemming
addiction, remain quite expensive, and the intensity and duration
of services is sizable as compared to science-based interventions
provided before risk turns into reality.
Although
early intervention programs may require greater up-front costs
than other prevention strategies, they can ultimately be very
cost-effective, if used appropriately. With a careful process
of screening and referral, practitioners can identify many individuals
and groups who might eventually abuse drugs or alcohol and intervene
before problems begin. This can ultimately reduce reliance on
government resources such as welfare and Medicaid.
In
addition, early intervention helps link troubled youths and troubled
families to much-needed social support, counseling, and health
care services. Children and youth just beginning to use substances
may be self-medicating for mental illness, or may be suffering
from child abuse or neglect. Identifying children whose behavior
indicates a risk of alcohol, tobacco, or other drug use can help
service providers identify families in crisis. Practitioners can
then provide more comprehensive services that go beyond the crisis
point and into the creation of healthier families.
Many
of the important findings about the effects of early intervention
come from research on juvenile crime and delinquency. These findings
have implications for substance abuse prevention as well, since
the same risk and protective factors apply to the whole spectrum
of juvenile behavioral problems. The risk factors for substance
abuse are similar to those for other problems, such as violence,
gang affiliation, delinquency, school dropout, unsafe sexual practices,
and adolescent pregnancy. Thus, substance abuse prevention programs
have the capacity to prevent or reduce other serious health and
behavioral problems among youth. And, programs designed to reduce
antisocial or delinquent behavior in general can reduce risks
of adolescent consumption of alcohol, tobacco, or other drugs.
At
its most basic level, early intervention provides needed support
services, making sure individuals and families can meet their
basic needs of food, shelter, and health care, and easing situations
of crisis to create a more stable environment. Early intervention
strategies then strive to reduce risk factors (such as family
instability, poor parenting, unhealthy peer associations, poverty,
and developmental disruptions) and enhance known protective factors
(such as support networks, family strengths, critical thinking
and problem-solving skills, education, literacy, mentoring, and
positive role models).
The
following examples of early intervention span the lifetime of
a young person, starting prenatally and continuing through adolescence.
Each of these strategies, properly implemented, can reduce the
risk factors associated with substance abuse. Ideally, youth at
risk will encounter a combination of these strategies. The science
on prevention seems to be fairly consistent in showing that early,
comprehensive programs touching on multiple risk factors in different
domains—individual, school, family, peer group, community—have
the greatest impact on later behavior.
STARTING
EARLY IN LIFE
In
the true spirit of early intervention, social service and health
practitioners are seeking to reach children at a very early age.
Children born to young later mothers with unstable lives and a
lack of parenting skills may be at higher risk for developing
behavioral problems, including substance abuse, later in life.
Families facing the difficulties of poverty and unemployment may
have greater difficulties in establishing an effective home life,
and children’s development can suffer as a result. By working
with parents and enhancing the home environment, prevention specialists
can help children avoid the risk factors that place them at high
risk for substance abuse and other unhealthy behaviors. Programs
such as the Prenatal and Early Childhood Nurse Home Visitation
program and Early Head Start are promising models.
Prenatal
home visitation programs enable practitioners to reach families
just as they are beginning to form. Unhealthy practices by mothers
during pregnancy can lead to low birth weight, premature delivery,
and developmental impairment. Following birth, poor parenting
skills or early child abuse and neglect can have serious effects
on a child’s social development. Difficulties in the mother’s
life course can also present obstacles to the stable home environment
necessary for healthy families. Prenatal and early childhood visitation
programs seek to reduce these risk factors by beginning to work
with the family even before the child is born, and continuing
through the first two years of the child’s life.
Prenatal
and Early Childhood Nurse Home Visitation: An Illustration
Prenatal
and Early Childhood Nurse Home Visitation is an in-home support
and skill-building program for low-income women who are pregnant
with their first child, especially those who are young and unmarried.
Beginning
as early in the pregnancy as possible, expectant mothers receive
visits from trained female nurses. Visits last 60 to 90 minutes
and occur once a week for the first four weeks of the program,
then every other week until delivery. These visits focus on ensuring
a healthy pregnancy: monitoring diet and weight gain; stopping
tobacco, alcohol and other drug use; seeking necessary prenatal
care; and preparing for labor, delivery, and care of the newborn.
Following
delivery, mothers receive an established protocol of services:
weekly visits for six weeks, bimonthly visits until the 21st month,
and monthly visits for the final three months of the program.
During this time, the intervention focuses on providing for the
physical care of the newborn (including safety and child care),
teaching parenting skills, helping mothers understand child temperament
and emotional needs, and helping mothers plan for their futures.
Throughout
the program, nurses seek to enhance the mother’s support
networks, including family, friends, significant other, and the
social service system. The nurses communicate with the mother’s
doctor and also help link her to social services such as public
assistance, Medicaid, WIC, Planned Parenthood, counseling services,
and education or job training. An evaluation of the program in
Elmira, New York, including a 15-year follow-up study, showed
a variety of positive outcomes as compared to a control group.2
These included:
- 75
percent reduction in pre-term deliveries
- 79
percent fewer reports of child abuse or neglect, compared to
a control group
- 83
percent increase in mother’s work force participation by
the child’s fourth birthday
- 44
percent fewer maternal behavioral problems due to alcohol and
drug abuse
- 25
percent reduction in smoking during pregnancy
- 56
percent fewer arrests among the 15-year-old children
- 56
percent fewer days of alcohol consumption by the 15-year-old
children
- Reduced
cigarette smoking and fewer behavioral problems related to alcohol
and drug use among the 15-year-old children.
Head
Start is a well-known and highly researched Federal child development
program for low-income families, founded in 1965. Head Start provides
targeted services to pre-school-aged children and their families,
with an emphasis on preparing children for success in school.
In 1994, in light of a trend to start even earlier in a child’s
development, the Head Start program created Early Head Start to
prevent developmental delays in the critical early childhood years
of 0 to age 3. Developmental delays can impede the development
of cognitive, emotional, and social skills that serve as protective
factors throughout the life span.
Early
Head Start is similar to the Prenatal and Infancy Nurse Home Visitation
Program in that it focuses on parenting skills and family stability.
A major goal of Early Head Start is to encourage close, supportive
relationships between parents and their young children. Programs
are either home-based, center-based, or a combination of the two.
An intensive evaluation of Early Head Start, begun in 1995, and
targeted for completion in 2002, has revealed highly promising
preliminary results for improving child development.
How
Do I Know This Works?
The
controlled research on the Prenatal and Early Childhood Nurse
Home Visitation Program described above is considered particularly
promising as a substance abuse prevention strategy. However, as
with other substance abuse prevention programs, it is difficult
to establish a direct correlation between a program for infants
and behavior in adolescents. The research thus far does support
the notion that these interventions reduce the risk factors associated
with substance abuse, and that they enhance the protective factors
associated with family stability.3 These short-term
effects may have powerful long-term effects on family behaviors
and individual behaviors.
In
addition, a longitudinal study on adolescent health risk behavior
found that decreasing tobacco, alcohol, and other drug use in
pregnant women may help prevent later substance abuse in both
the mother and the child.4
The
Early Head Start program provides another viable model. After
a year or more of program services, when compared with a randomly
assigned control group, 2-year-old Early Head Start children performed
significantly better on a range of measures of cognitive, language,
and social-emotional development. Their parents scored significantly
higher than control group parents did on many of the measures
of the home environment, parenting behavior, and knowledge of
infant-toddler development.5
How
Can This Strategy Be Used in My Community?
Prenatal
home visits can be a particularly viable way to reach at-risk
families who might not otherwise be identified. Pregnancy is a
time ripe for intervention: expectant mothers are often more willing
to decrease alcohol or other drug use, stop smoking, seek health
care, and sign up for parenting classes during this time. Because
many at-risk mothers are teenagers themselves, prenatal home visits
also enable nurses to recognize and prevent substance abuse problems
among these young people as well.
In
addition, young mothers may be more willing to receive the services
of trained medical nurses than of other types of service providers,
such as social workers. Nurses bring the trust of the medical
profession into the home of young mothers, treating pregnancy
and early childhood as a health issue. Thus, substance abuse—and
its prevention—is treated within a public health context.
The
nurse home visitation program costs an estimated $2,800 per family
per year once the nurses have been fully trained.6
When the program focuses on low-income women, some studies suggest
that these costs can be recovered by the time the child reaches
age 4 because of the reduced number of subsequent pregnancies
and the reduction in use of government health and welfare programs.7
In
addition, early childhood development programs such as Early Head
Start are warmly welcomed by communities. The good name of the
Head Start program, plus the sizable funding available makes the
program an attractive option for communities looking for an effective
family development model. It can also be linked to Head Start
programs to provide a continuum of care for families with young
children.
SKILL-BUILDING
AND EARLY EDUCATION FOR CHILDREN AND YOUTH
Alcohol,
tobacco, and other drug use is starting earlier and earlier among
youth. For young people to resist the temptations of alcohol,
tobacco, and other drugs, they need strong communication skills,
problem-solving abilities, high self-esteem, and the ability to
make healthy choices. While family stability and guidance are
crucial for helping children develop these resiliency factors,
research shows that early education and skills training directed
at youth can reduce unhealthy and self-destructive behaviors later
in life.8
Early
education programs such as Head Start boost child development,
cognitive abilities, and social skills, with a particular focus
on preparing children for school. By putting children on a more
"even" footing with their more-advantaged peers, Head
Start programs potentially elevate children’s self-esteem
and enhance factors known to promote healthy behaviors for life.
Skills
training programs for children generally focus on critical
thinking, problem-solving, anger management, and interpersonal
communication skills. Skills training is typically provided in
a classroom setting. While useful for all children, it particularly
provides a "pre-emptive strike" for young people who
need to enhance their communication, coping, or anger management
abilities.
"We
don’t just say to children, go solve your problem, because
if they don’t have the skills to do that, they feel more
lost, and more frustrated."
—Myrna
Shure, Ph.D, Developer, I Can Problem Solve
MCP Hahnemann University
Skill-Building
for Children: An Illustration
I
Can Problem Solve (ICPS), developed at MCP Hahnemann University
in Philadelphia, is both a preventive and rehabilitative program
to help children from preschool to grade six resolve interpersonal
problems and prevent anti-social behavior. Specifically, it focuses
on impatience, aggression, over-emotionality, and social withdrawal.
The program has been extensively evaluated. ICPS is based on the
theoretical position that improving problem-solving and thinking
skills can guide behavior and help children resolve their differences.
ICPS
is available for three levels—preschool, kindergarten and
primary, and intermediate elementary. It was originally designed
for use in nursery school and kindergarten, but it has also been
successfully implemented with children in grades 5 and 6. Throughout
the intervention, instructors use pictures, role-playing, puppets,
and group interaction to help develop students’ thinking
skills. Teachers also use real-life conflicts within the classroom
to demonstrate better problem-solving techniques on the spot.
Small
groups of 6 to 10 children receive the training for approximately
three months. The intervention begins with 10 to 12 lessons that
teach students basic skills and problem-solving language. For
example, children learn word concepts such as "not"
(e.g., acting or not acting); "some/all" (solutions
may succeed with some people but not all); "or" (discovering
alternative solutions); "if...then" (learning consequences
of actions); and "same/different" (thinking of multiple
solutions).
The
following dialogue illustrates how language such as "before"
and "after" is used to teach problem-solving skills:
Teacher:
"What happened before Peter hit you?" (Instead
of the more traditional question, "Peter, why did you hit
Luke?")
Luke: "Well, he hit me first."
Teacher: "Well, Luke, how did that make you feel when Peter
hit you?"(Instead of focusing on who really hit who first,
because she is unlikely to find out, anyway).
Luke: "Sad."
Teacher: "What happened after Peter hit you?"
Luke: "I hit him back."
Teacher: "How do you think that made Peter feel?"
Luke: "Sad."
Teacher: "Well, can you think of something different
to do so you both won’t feel mad or sad?"
Luke (then comes up with a solution): "Well, we can share
the toy."
Teacher: "Good thinking." (Now the child is beaming,
instead of angry and frustrated. Instead of saying, "That’s
a good idea," using the phrase "good thinking"
reinforces how the child thinks, not what he thinks.)
The
next 20 lessons help children identify their own feelings and
become more sensitive to others’ emotions. Then, during the
final 15 lessons, students generate solutions to hypothetical
problem situations and consider the possible consequences of their
decisions. Observers of the program note that the children become
much calmer and quieter, and the classroom environment becomes
a more understanding and peaceful environment for learning.
- Evaluations
of the ICPS program showed that a year of training was effective
in enhancing both cognitive problem-solving and behavioral skills.
Children in the program, compared to a control group, showed
fewer high-risk behaviors, improvement in pro-social behaviors,
and performed better on tests.9
- A
two-year study of inner city, low-income children in nursery
school and kindergarten demonstrated that ICPS children, compared
to control students, had improved classroom behavior and problem-solving
skills, even 3–4 years after the program.10
- A
replication with fifth and sixth grade students found that ICPS
children, compared to a control group, demonstrated an increase
in positive, pro-social behaviors; and healthier relationships
with peers, better problem-solving skills.11
"Often
a child will have a problem, and they get very frustrated when
their first solution doesn’t work, so, in this lesson I tried
to teach them that there’s more than one way, and if their
first solution doesn’t work, maybe their second solution
will work, or maybe their third solution will work."
—Lisa
Leslie, fourth grade teacher,
A.S. Jenks School, Philadelphia
How
Do I Know This Works?
- Evaluations
of I Can Problem Solve, as described above, reveal it to be
a promising skills training program, with significant effects
on social behaviors, school performance, and other protective
factors.
- The
Federal Head Start program, for children ages 3 to 5, has been
extensively researched, with such demonstrated effects as enhanced
learning abilities and school achievement on par with national
averages (often at a significantly improved level to when the
children began the Head Start program). In addition, Head Start
families may be less likely to rely on government programs and
to show steady improvements in their living conditions.12
Free to Grow, a specialized Head Start program for substance
abuse prevention is currently being piloted and may shed light
on the efficacy of a Head Start model to reduce substance use
among teenagers who participated in the program early in life.13
- Programs
such as Head Start and I Can Problem Solve are targeted to younger
children. However, other science-based programs for adolescents
can also be effective in reducing adolescent substance abuse.
A study of adolescents treated for drug use found that social,
problem solving, self-control, and drug and alcohol avoidance
skills were significantly related to marijuana use, variety
and severity of drug use, and intentions to use drugs or alcohol.14
FAMILY-BASED
SKILL-BUILDING
The
family is a critical domain for intervention to prevent substance
abuse. Parental and sibling substance use, inconsistent family
discipline practices, economic instability, and low family bonding
can increase young people’s risks of poor health outcomes
and a range of unhealthy behaviors.
Programs
that reduce behavioral problems in children and youth by improving
family functioning can reduce the likelihood that the children
will later abuse substances and engage in risky or self-destructive
behaviors. Ideally, family-based interventions for high-risk groups
start very early, either prenatally or shortly after childbirth.
However, children from at-risk families can elude the system until
they enter school. Once children reach school age, teachers and
others in the school system can identify troubled youngsters and
refer them for services to prevent problems from getting worse.
Family
and parenting skill-building sessions enable families to better
nurture their children and promote pro-social behaviors. Skill-building
focuses on improving the communication, discipline, and family
interaction patterns to help families respond more effectively
to problems that do arise. Perhaps most importantly, programs
must identify, acknowledge, and build upon families’ strengths
as the starting point for effecting change.
Strengthening
Families Program: An Illustration
The
Strengthening Families Program (SFP) is a family skills-training
intervention targeted at 6- to 10-year-old children considered
to be at risk for substance abuse. The program was originally
developed in Utah for children deemed to be at risk because their
parents abused alcohol or other drugs. It has since been tested
in a variety of settings, including with children who are already
demonstrating behavioral risk factors for substance abuse. SFP
has also been adapted for use with African-American families,
Asian/Pacific Islanders, rural families, young teens in the Midwest,
and Hispanic families.
SFP
participants meet for two hours weekly for 14 weeks, in groups
of 5 to 14 families. During the first hour, parents and children
attend separate sessions; during the second hour, children and
parents attend joint training sessions to spend time working together
as a family.
- Parent
Skills Training focuses on improving a range of parenting skills:
increasing desired behaviors in children by showing attention,
praise, and empathy for their children; increasing use of effective
discipline while diminishing use of physical punishment; and
decreasing parental use of substances.
- Children’s
Skills Training teaches young people to resist peer pressure,
understand and cope with their feelings, communicate, follow
group rules, and understand the dangers of alcohol, tobacco,
and other drugs.
- Family
Skills Training enables the parents and children to practice
their skills in structured family interactions. A series of
games enable the parents to introduce rules to their children
with their increased insight into children’s behavior,
emotions, and needs.
The
Strengthening Families Program has been rigorously evaluated and
shown to have significant impact on family relationships and children’s
behaviors,15 including:
- Improved
parenting skills, decreased use of physical punishment, and
decreased parental substance abuse
- Reduction
in child risk factors, including decreased behavior problems,
improved emotional status, increased pro-social behavior
- Reduced
intention for young people to use tobacco and alcohol, as reported
by youths in the program
How
Do I Know This Works?
- Family
skills training programs modeled after Strengthening Families
can be a viable strategy for reducing not only substance abuse
but also other behavioral and familial problems. Research, including
the evaluations of Strengthening Families described above, has
consistently shown that interventions targeting the entire family
can prevent youth substance abuse.16
- Studies
of teenage initiation of alcohol, tobacco, and other drug use
reveal that proactive parents and clear family standards can
delay adolescent involvement with substances.17
- Because
family skills training programs generally include multiple components:
parent behavioral training, child skills training, and family
behavioral therapy, they address a greater number of risk and
protective factors than programs just targeting the child, the
parent, or the family alone.18
- The
family skills training approach has also been shown to be effective
for minority families. The Safe Haven Program is a skills training
program for inner-city African American families in which one
parent has a substance abuse problem. This program has been
found to improve parenting skills and reduce illegal substance
abuse.19
- Interventions
combining comprehensive family support with early education
may bring about long-term prevention through short-term protective
effects on multiple risks. A review of the early intervention
literature reveals that the family support component is associated
with effects on family risks, while the early education component
is associated with effects on child risks. Both components may
be optimal for effects on multiple risks and later reductions
in unhealthy or antisocial behaviors.20
How
Can This Strategy Be Used in My Community?
Family
skill-building programs such as Strengthening Families can be
successfully integrated into a variety of community-based family
services and settings. The programs should be accessible and held
in facilities that are easy for people to reach: community centers,
churches, schools, and housing developments.
Providing
transportation, meals, recreational activities, and child-care
can greatly increase participation in a family training program
and increase retention of the participants who do get involved.
Several studies examining the use of incentives have found that
80 to 85 percent retention rate in programs that offer such services.21
Interventions
must also pay special attention to cultural issues and needs and
should be shaped to be culturally appropriate. Ideally, interventions
are led by or sponsored by individuals or groups who are part
of the family’s culture or community, or who are familiar
with the particular issues of the family’s cultural heritage,
traditions, family structure, and communication styles.
INTERVENTION
FOR TROUBLED YOUTH
Once
young people have started to engage in drinking, smoking, or other
drug use, intervention must be more intensive to prevent the behavior
in the future. The most vulnerable years for initiating substance
abuse are between the ages of 12 and 20. At this stage, early
interventions can form a nexus between prevention and treatment,
intercepting young people soon after they start drinking, smoking,
or using drugs.
Schools
are a useful domain for early intervention, since behavior changes
at school are often the first indicator of other problems in a
child’s life. School guidance programs across the country
are increasingly offering specialized Student Assistance Programs
(SAPs), which provide screening and assessment to channel young
people into a variety of therapeutic and counseling programs.
SAPs are one of a number of indicated interventions for youths
who show signs of substance use problems.
Student
Assistance Programs: An Illustration
Student
Assistance Programs (SAPs), modeled after Employee Assistance
Programs used in many workplaces, are school-based programs that
view substance abuse as a barrier to student development and learning.
Using the leverage of the school, SAPs identify young people who
are using alcohol, tobacco, and other drugs and refers them to
community agencies for assessment and treatment. Comprehensive
in nature, SAPs generally do not limit their activities to alcohol,
tobacco, and other drug problems. Instead, they focus on identifying,
referring, and assisting students with all issues causing problems
that hinder a student’s development.
The
purpose of SAPs is to provide school staff with a mechanism for
helping youth with a range of problems that may contribute to
alcohol, tobacco, and other drug use. Teachers, guidance counselors,
and other school staff are trained to identify youths experiencing
problems and refer them to appropriate assessment and assistance
resources.
How
Do I Know This Works?
SAPs
have been shown to correlate with decreases in substance use by
high school students:
- Students
from schools with a SAP in one controlled study reported a lower
use of alcohol in the previous 30 days, compared with students
without a SAP, and they also reported a significant difference
in academic achievement.22
- One
study, which surveyed 144 high school seniors who had completed
counseling through a SAP, found that students reported significant
decreases in substance use and attributed these changes to counseling.23
How
Can This Be Used in My Community?
SAPs
are in place in many schools across the country, especially those
with comprehensive school health programs. The National Association
of Student Assistance Professionals offers training and technical
assistance in developing and implementing these programs.
Student
assistance programs components
The National Association of Student Assistance Professionals recommends
that, at a minimum, all SAPs have the following components:24
- School
board policies that define the school’s role in creating
a safe, disciplined and substance-free learning community and
clarify the relationship between student academic performance
and the use of alcohol, other drugs, violence and high-risk
behavior
- Training
for all school employees to provide the necessary foundation
of attitudes and skills to reduce risks, increase protective
factors and foster resilience through SAP services
- Program
awareness campaigns to educate parents, students, agencies
and the community about the school policy on alcohol, tobacco,
other drugs, disruptive behavior and violence and provide information
about Student Assistance Programs that promote resilience and
student success
- Internal
referral process to identify and refer students with academic
and social concerns to a multi- disciplinary problem-solving
and case management team
- Problem-solving
team and case management to evaluate how the school can
best serve students with academic or social problems through
solution-focused strategies
- Program
evaluation to ensure continuous quality improvement of Student
Assistance Programs and outcomes
- Educational
student support groups to provide information, support and
problem-solving skills to students who are experiencing academic
or social problems
- Cooperation
and collaboration with community agencies and resources
to build bridges between schools, parents, and community resources
through referral and shared case management
- Integration
with other school-based programs designed to increase resilience,
improve academic performance, and reduce risk for alcohol, tobacco,
other drugs, and violence
THERAPUTIC
INTERVENTIONS FOR YOUTH AND THEIR FAMILIES
Student
Assistance Programs are effective for reaching certain youth exhibiting
behavioral problems, while other adolescents may benefit from
therapies targeted to the entire family. Family therapy is becoming
the treatment of choice for many juvenile behavioral and mental
health disorders. Adolescents face enough challenges from their
peers, and without a supportive, healthy family environment, they
will find it very difficult to resist the pressures to use and
abuse alcohol, tobacco, and other drugs.
Family
therapies range in intensity and content. Shorter-term programs
focus on behavioral training to restructure family interactions.
Longer, more intensive programs can assess the entire system in
which a young person functions, enlisting the entire family to
examine the network of influence over the child and make realistic
improvements to ensure that social and functional supports are
firmly in place.
Two
models are provided here as examples. Functional Family Therapy
is a short-term behavioral training model. Multisystemic Therapy
is a more intensive strategy that engages the family in making
systemic changes in many areas of a young person’s social
network.
Functional
Family Therapy: An Illustration25
Functional
Family Therapy (FFT) is a therapeutic intervention for youth ages
11–18, at risk for or presenting with delinquency, violence,
substance use, or conduct disorders. While commonly used as an
intervention program for court-referred youth, FFT has demonstrated
its effectiveness as a method for preventing many of the problems
of at-risk adolescents and their families, including juvenile
substance abuse. FFT is intensive and outcome-driven, generally
requiring as little as 8 to 12 hours of direct service or up to
30 hours for more difficult cases, usually over a three-month
time period, by licensed therapists.
FFT
focuses on preserving the preferred "functions" of each
family member within the family unit as a whole, while working
to improve dynamics and interactions to reduce problematic behaviors.
The therapeutic process consists of a series of phases that build
upon one another: whole, while working to improve dynamics and
interactions to reduce problematic behaviors. The therapeutic
process consists of a series of phases that build upon one another:
- Engagement,
during which the therapist strives to create a positive initial
reaction and enhance the family’s willingness to stay involved
in the program
- Assessment,
designed to clarify individual, family system, and larger system
relationships, especially interpersonal behaviors, with an emphasis
on identifying family strengths and processes
- Motivation,
designed to decrease maladaptive emotional reactions and intense
negativity and create a context in which family members feel
hopeful that change can occur
- Behavior
Change, which consists of communication training and the teaching
of basic parenting techniques
- Generalization,
during which the therapist acts as a "family manager"
to connect family members to adjunct community services and
anchor the family in a larger supportive community, based on
the individual family’s dynamics and needs
Nearly
30 years of rigorous investigation have examined the effectiveness
of Functional Family Therapy in improving family dynamics and preventing
antisocial behaviors in youth. Controlled studies have demonstrated
the following effects of FFT:
- Reduction
in rates of re-offending ranging from 25 percent to 60 percent26
- Reduction
in subsequent units of service to family by as much as 50 percent27
- Reduction
in subsequent court referrals for siblings by 20 to 43 percent28
A
current study funded by the National Institute on Drug Abuse at
the University of New Mexico is examining the effects on adolescents
with substance abuse disorders of Functional Family Therapy compared
to a self-regulation skills training program for individual adolescents.
A
more intensive way to leverage family strengths comes in the form
of a comprehensive intervention known as Multisystemic Therapy,
which is gaining recognition as a highly effective treatment for
youths who have started to act out in antisocial or violent ways.
Multisystemic
Therapy: An Illustration
Multisystemic
Therapy (MST) is an intensive, family-based therapeutic approach
that addresses the multiple factors correlated with serious antisocial
behavior in adolescents. MST targets chronic, violent, or substance
abusing male or female juvenile offenders, ages 12 to 17, at high
risk of out-of-home placement, and the offenders’ families.
The
highly individualized treatment approach views youths as embedded
within the interconnected systems of family, peers, school, work,
and neighborhood, and attempts to change the youth’s behavior
by intervening at different points within these systems. MST programs
focus on improving parental discipline, enhancing familial relationships,
decreasing the youth’s association with troubled peers, increasing
the young person’s involvement with pro-social peers and
positive social activities, and improving his or her school and
work performance. The family and therapist work together to develop
an extended network of relatives, neighbors, teachers, and friends
to help support the family and the youth in making the necessary
changes.
MST
therapists are rigorously trained and have low caseloads that
enable them to be available 24 hours a day. The average length
of treatment is four months, with approximately 50 hours of face-to-face
contact between the therapist and family.
The
multi-systemic approach has been found to be quite promising in
treating delinquent and violent youths, who are often at risk
of using drugs and alcohol or who may already be regular users.
Research with chronic and violent juvenile offenders has demonstrated
the capacity of MST to reduce long-term rates of recidivism.29,30
In
addition, in one study of juvenile offenders diagnosed with substance
abuse or dependence, a multisystemic therapy program reduce alcohol,
marijuana, and other drug use immediately after program completion.31
How
Do I Know This Works?
In
addition to the studies on Functional Family Therapy and Multisystemic
Therapy, described above, a variety of family therapy models have
shown promise in improving family functioning, increasing parenting
skills, and decreasing recidivism of juvenile offenders.32
Research also demonstrates that family therapy can be effectively
included as one component of a comprehensive prevention effort.33
How
Can This Strategy Be Used in My Community?
Family
therapy, while cost- and time-intensive, may reduce youths’
future need for services, and ultimately reduce delinquency, incarceration,
and residential treatment. It can also have positive effects on
younger siblings, thereby preventing problem behaviors before
they start. Functional Family Therapy is one science-based model
that demonstrates promising results with relatively few treatment
hours, making it relatively cost-effective when compared to the
alternatives.
Multisystemic
Therapy, which requires a greater number of hours of direct service,
has also been shown to be particularly cost-effective. When compared
with the usual mental health and juvenile justice services provided
for this population of young people—such as detention, probation,
or residential treatment—MST is considered among the most
cost-effective.34
Other
special considerations include the following:35
- Because
families in crisis often receive services from multiple agencies,
family therapists should be linked with other social service
providers through case management and interagency collaboration.
- Practitioners
may need to destigmatize family therapy by educating the target
population and the community about the benefits of the therapeutic
process, and by marketing the program in a way that will be
most acceptable to potential clients.
- Therapists
should be culturally competent and knowledgeable about the values,
beliefs, and traditions of families and knowledgeable about
culturally appropriate resources in the community.
- Because
therapeutic interventions require highly trained professionals
and individualized services for clients, practitioners need
to determine the appropriate level of risk in their populations
to determine whether such strategies are feasible and indicated.
CONCLUSION
Early
intervention is generally indicated for youth and families in
which substance abuse poses a threat, either because there is
a combination of risk factors that may predispose a child to initiate
alcohol, tobacco, or drug use, or because the family or child
already shows a problematic involvement with substances. The early
intervention strategies described in this paper represent just
a few of the approaches being used to reduce substance abuse in
at-risk juvenile populations. Prevention specialists should examine
the variety of interventions to determine which ones are the most
appropriate for their settings and communities.
The
Center for Substance Abuse Prevention provides a few, straightforward
guidelines that can aid practitioners in implementing the most
effective early intervention programs.
How
Can Practitioners Have the Greatest Impact?36
In
determining the best prevention strategies for people in their communities,
practitioners should keep in mind the following guidelines:
- Select
prevention approaches according to the risk level of the targeted
families
- Focus
on families with young, pre-school or school-aged children (before
negative behaviors and problems become entrenched)
- Reduce
exposure to risks
- Enhance
protective factors
- Choose
strategies that are developmentally, culturally, and gender
appropriate
- Develop
interventions in multiple contexts and settings (schools, religious
institutions, neighborhoods, homes)
- Address
multiple risk factors simultaneously
- Build
on families’ strengths and encourage their leadership
Early
Intervention Resources
Program
Contacts
Functional
Family Therapy (FFT)
For information about program research, contact:
James F. Alexander, Ph.D.
Department of Psychology
University of Utah
390 S 1530 E, Room 502
Salt Lake City, UT 84112
(801) 581-6538
(801) 581-5841 FAX
jfafft@psych.utah.edu
http://www.fftinc.com
I
Can Problem Solve (ICPS)
Myrna B. Shure, Ph.D.
MCP - Hahnemann University
Clinical and Health Psychology Department
Broad and Vine Streets, MS 626
Philadelphia, PA 19102-1192
(215) 762-7205
(215) 762-8625 FAX
mshure@drexel.edu
Multisystemic
Therapy (MST)
Scott W. Henggeler, Ph.D.
Family Services Research Center
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
67 President St, Suite CPP
PO Box 250861
Charleston, SC 29425
(843) 876-1800
(843) 876-1845 FAX
henggesw@musc.edu
Prenatal
and Infancy Home Visitation by Nurses
(Now called Nurse-Family Partnership)
Ruth O’Brien
National Center for Children, Families, and Communities
1825 Marion Street
Denver, CO 80218
(303) 864-5210
(303) 864-5236 FAX
obrien.ruth@tchden.org
National
Association of
Student Assistance Professionals
4200 Wisconsin Avenue, NW
Suite 106-118
Washington, DC 20016
(800) 257-6310
(215) 257-6997 FAX
http://www.nasap.org
Strengthening
Families Program (SFP)
Karol Kumpfer, PhD
University of Utah
Department of Health and
Prevention Education
250 South, 1850 East, Room 215
Salt Lake City, UT 84112-0920
(801) 581-7718
(801) 581-5872 FAX
karol.kumpfer@hsc.utah.edu
http://www.strengtheningfamilies.org
Head
Start
330 C Street, SW
Washington, DC 20447
(202) 205-8572
http://www2.acf.dhhs.gov/programs/hsb/
EARLY
INTERVENTION PUBLICATIONS
CSAP’s
Decision Support System (DSS) at http://www.preventiondss.org
promotes scientific methods and programs for substance abuse prevention
for use within communities and State prevention systems. You can
use this site to learn how to assess your needs, gain insight
into how to further develop your agency capacity, and choose among
effective prevention programs.
Lang,
C. and Krongard, M. (1999). Strengthening Families and
Protecting Children from Substance Abuse: A Guide for Practitioners
and State and Local Policymakers. CSAP’s Northeast Center
for the Application of Prevention Technologies. Newton, MA: Education
Development Center, Inc. A comprehensive guide focusing on enhancing
family strengths in the effort to prevent youth substance use.
Describes relevant research behind substance abuse prevention,
discusses five family-based strategies and the evidence that supports
them, and offers guidelines for applying these strategies in local
programs. Located at http://www.northeastcapt.org/services/products/papers/family/
Preventing
Substance Abuse Among Children and Adolescents: Family-Centered
Approaches, (1998). Prevention Enhancement Protocols System
(PEPS), Center for Substance Abuse Prevention DHHS Publication
Nos. 3223-FY98 and 3224-FY98. Examines research evidence for family-focused
substance abuse prevention strategies, including parent and family
skills training, family in-home support, and family therapy. Available
in three formats: Reference Guide, Practitioner’s Guide,
and Parent and Community Guide.
Drug
Abuse Prevention for At-Risk Individuals, (1997). National
Institute on Drug Abuse. NIH Publication No. 97-4115. A resource
manual describing the concept of indicated prevention as it relates
to drug abuse and related problems. Provides an in-depth description
of the Reconnecting Youth Program.
Drug
Abuse Prevention for At-Risk Groups, (1997). National Institute
on Drug Abuse. NIH Publication No. 97-4114. A resource manual
describing the concept of selective prevention as it relates to
drug abuse and related problems. Provides an in-depth description
of the Strengthening Families Program.
CSAP’s
Northeast CAPT |
CSAP |
| Policy |
Environmental
Approaches |
| Enforcement |
Environmental
Approaches |
| Collaboration
|
Community-Based
Processes |
| Communications |
Information
Dissemination |
| Education |
Prevention
Education |
| Early
Intervention |
Problem
Identification & Referral |
| Alternatives |
Alternatives |
ENDNOTES
1Gardner,
S. E., and Brounstein, P. J. (2001). Science-Based Prevention
Practices. Principles of Substance Abuse Prevention. Rockville,
MD: U.S. Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration, Center for Substance
Abuse Prevention, Division of Knowledge Development and Evaluation.
Available online: http://www.northeastcapt.org/csap/papers/gardner-cover2.asp
2Olds,
D., Hill, P., and Rumsey, E. (Nov. 1998). Prenatal and early childhood
nurse home visitation. OJJDP Juvenile Justice Bulletin,
1; Olds, D., Eckenrode, J., Henderson, C.R., Jr., Kitzman, H.,
Powers, J., Cole, R., Sidora, K., Morris, P., Pettitt, L., and
Luckey, D. (1997). Long-term effects of home visitation on maternal
life course and child abuse and neglect: 15-year follow-up of
a randomized trial. Journal of the American Medical Association,
278(8):637-643. Olds, D., Henderson, C.R., Cole, R., Eckenrode,
J., Kitzman, H., Luckey, D., Pettitt, L., Sidora, K., Morris,
P., and Powers, J. (1998). Long-term effects of nurse home visitation
on children’s criminal and antisocial behavior: 15-year follow-up
of a randomized trial. Journal of the American Medical Association,
280(14):1238-1244. Olds, D.L., Henderson, C.R., and Tatelbaum,
R. 1994b. Prevention of intellectual impairment in children of
women who smoke cigarettes during pregnancy. Pediatrics,
93(2):228-233. Olds, D., Henderson, C. R., Tatelbaum, R., and
Chamberlin, R. 1986. Improving the delivery of prenatal care and
outcome of pregnancy: A randomized trial of nurse home visitation.
American Journal of Public Health, 78(11):1436-1445.
3Olds,
D., Hill, P. and Rumsey, E. (Nov. 1998). Prenatal and early childhood
nurse home visitation. OJJDP Juvenile Justice Bulletin,
1; Olds, D., Eckenrode, J., Henderson, C. R., Jr., Kitzman, H.,
Powers, J., Cole, R., Sidora, K., Morris, P., Pettitt, L., &
Luckey, D. (1997). Long-term effects of home visitation on maternal
life course and child abuse and neglect: 15-year follow-up of
a randomized trial; Olds, D., Henderson, C.R., Cole, R., Eckenrode,
J., Kitzman, H., Luckey, D., Pettitt, L., Sidora, K., Morris,
P., & Powers, J. (1998). Long-term effects of nurse home visitation
on children’s criminal and antisocial behavior: 15-year follow-up
of a randomized trial.
4Resnick,
M., Bearman, P. S., Blum, R. W., Bauman, K. E., Harris, K. M.,
Jones, J., Tabor, J., et al. (1997). Protecting adolescents from
harm. Journal of the American Medical Association, 278(10):823-32.
5Commissioner’s
Office of Research and Evaluation and the Head Start Bureau. (2001).
Building their futures: How early Head Start programs are enhancing
the lives of infants and toddlers in low-income families, summary
report. Washington, DC: Administration on Children, Youth
and Families, U.S. Department of Health and Human Services.
6Olds,
D., Hill, P. & Rumsey, E. (Nov. 1998). Prenatal and early
childhood nurse home visitation. OJJDP Juvenile Justice Bulletin,
1.
7Olds,
D., Henderson, C., Phelps, C., Kitzman, H., & Hanks, C. 1993.
Effect of prenatal and infancy nurse home visitation on government
spending. Medical Care, 31(2):155-74.
8Botvin,
G. J., Baker, E., Dusenbury, L. D., Botvin, E. M., & Diaz,
T. (1995). Long-term follow-up results of a randomized drug abuse
prevention trial in a white middle-class population. Journal
of the American Medical Association, 273(14): 1106-12; Botvin,
G. J., Schinke, S. P., Epstein, J. A., Diaz, T. (1994). Effectiveness
of culturally focused and generic skills training approaches to
alcohol and drug abuse prevention among minority youths. Psychology
of Addictive Behaviors, 8: 116-27.
9Shure,
M. B. (1993). Interpersonal problem solving and prevention: 5
year longitudinal study. A comprehensive report of research and
training. #MH-40801. Washington, DC: National Institute of Mental
Health.
10Shure,
M. B. & Spivack G. (1982). Interpersonal problem-solving in
young children: a cognitive approach to prevention. American
Journal of Community Psychology, 10(3):341-56.
11Shure,
M. B. (1984). Problem solving and mental health of 10- to 12-year
olds. Final report of research and training. #MH-35989.
Washington, DC: National Institute of Mental Health.
12Civitan
International Research Center, University of Alabama at Birmingham.
(2000). Head Start children's entry into public school: A report
on the National Head Start/Public School Early Childhood Transition
Demonstration Study. Birmingham, AL: University of Alabama
at Birmingham.
13Jones,
J. E., Gutman, M. A., Kaufman, N. J. (1999). Free to Grow: Translating
substance abuse research and theory into preventive practice in
a national Head Start initiative. Journal of Primary Prevention,
19(4): 279-96.
14Jenson,
J. M., Wells, E. A., Plotnick, R. D., Hawkins, J. D., Catalano,
R. F. (1993). The effects of skills and intentions to use drugs
on post-treatment drug use of adolescents. American Journal
of Drug and Alcohol Abuse, (1):1-18.
15Kumpfer,
K. L. & Alvarado, R. (November 1998). Effective family strengthening
interventions. OJJDP Juvenile Justice Bulletin; Kumpfer,
K. L., DeMarsh, J., & Child, W. (1997). The Strengthening
Families Program (SFP): A program description and overview. Department
of Health Education, University of Utah; Kumpfer, K. L. (1996).
Selective prevention approaches for drug abuse prevention: The
Strengthening Families Program. Paper presented at the NIDA conference
Drug Abuse Prevention through Family Intervention, Gaithersburg,
MD.
16Hawkins,
J. D., Catalano, R. F., Kosterman, R., Abbott, R., & Hill,
K. G. (1999). Preventing adolescent health-risk behaviors by strengthening
protection during childhood. Archives of Pediatric and Adolescent
Medicine, 153(3):226-34; Dent, C. W., Sussman, S., Stacy,
A. W., Sun, P., Craig, S., Simon, T. R., Burton, D., & Flay,
B. (1995). Two-year behavioral outcomes of Project Toward No Tobacco
Use. Journal of Consulting Clinical Psychology, 3(4): 676-7;
Dishion, T. J., Andrews, D. W., Kavanagh, K., & Soberman,
L.H. (1996). Preventing interventions for high-risk youth: The
Adolescent Transitions Program. In R. D. Peters & R. J. McMahon,
(Eds.), Preventing childhood disorders, substance abuse, and
delinquency. Thousand Oaks, CA: Sage Publications; Hawkins,
J.D., Catalano, R.F., & Miller, J.Y. (1992). Risk and protective
factors for alcohol and other drug problems in adolescence and
early adulthood: Implications for substance abuse prevention.
Psychological Bulletin, 112(1):64-105.
17Kosterman,
R., Hawkins, J. D., Guo, J., Catalano, R. F., & Abbott, R.
D. (2000). The dynamics of alcohol and marijuana initiation: patterns
and predictors of first use in adolescence. American Journal
of Public H
