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Innovations in Prevention: Youth Substance Abuse & Dating
ViolenceChristine Wekerle, Ph.D. The University of Western Ontario
[email protected]
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)
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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?
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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)
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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
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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)
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Key Windows of Opportunities
Perinatal and Early Childhood Programs targeting parents,
infants, young children
Education Programs targeting school-age children and teens
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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
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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)
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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
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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
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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.
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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.
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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)
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Points for Developmental TimingDevelopmental Tasks:Emotional
Autonomy Behavioural IndependenceIdentity Sexuality & Romantic
RelationshipsSchool Achievement & Career Planning
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Stages of Change (Transtheoretical Model of Change; Prochaska,
DiClemente, & Norcross, 1992)
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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
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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.
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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
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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?
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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
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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)
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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**
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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
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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
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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
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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