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Innovations in Prevention: Youth Substance Abuse & Dating Violence


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Innovations in Prevention: Youth Substance Abuse & Dating Violence

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Innovations in Prevention: Youth Substance Abuse & Dating Violence

  1. 1. Innovations in Prevention: Youth Substance Abuse & Dating Violence Christine Wekerle, Ph.D. The University of Western Ontario “ Violence in intimate relationships can be one…in 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)
  2. 2. Similar Examples: Different Outcomes • Developmental context – relationships • Perhaps type of relationship - attachment • Topographically similar events • Functionally similar behaviours – to a point • Affectively similar – to a point • Good cognitive awareness of event • How to change? Motivation to change? • Would change or self-correction occur on its own?
  3. 3. Natural Reduction Processes Teens who stop drinking (D’Amico et al., 2001; Brown, 2001) 1. Independent Effort (willpower, forced myself) 2. Structured Activity (sports, hobbies, church) 3. 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)
  4. 4. Universal Prevention Interventions 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, D’Amico et al., 2001) Query: How to reach more youth? (e.g., building into school curriculum; use medical settings)
  5. 5. Selected Prevention Interventions 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 behaviour • 10% of youth report 3-4 problems (OSDUS, 2003)
  6. 6. Key Windows of Opportunities 1. Perinatal and Early Childhood Programs targeting parents, infants, young children 2. Education Programs targeting school-age children and teens
  7. 7. Distal Factor: Child Maltreatment Effective 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 who’ve never had any. Bill Cosby
  8. 8. Substance-Abusing Caregivers Reported to Child Welfare – Poverty (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)
  9. 9. Canadian Incidence Study of Reported Child Abuse & Neglect: Caregiver Substance Abuse 65%decrease OR: 0.35; CI: 0.14, 0.90* 61%increase OR: 1.61; CI: 1.17, 2.21* 155%increase OR: 2.55; CI: 1.90, 3.42* 6%decrease OR: 0.94; CI: 0.63, 1.41 -150% -100% -50% 0% 50% 100% 150% 200% Physical abuse Sexual abuse Neglect Emotional abuse ChildMaltreatment Type %increase/decreaseinriskformaltreatmentin associationwithcaregiversubstanceabuse age & sexof the child + the caregiver's characteristics accounted for *p>0.05
  10. 10. Child Maltreatment & Prevention – Lack 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
  11. 11. Assessing Impact: Community Report Card • Useful 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.
  12. 12. Effective Prevention: What You Need To Know & Why Baserates of problem behaviour  Outcome Targets Inter-relationships of behaviours  Multiple Targets Developmental trajectories  Developmentally- timed intervention Explanatory factors: Mediators  Change Targets Contextual factors: Moderators Matching to sub- groups
  13. 13. Baserates: Youth Substance Abuse & Dating Violence • 21% males; 17% females report hazardous drinking • 24% report drunkenness past month • 26% binge drink past month • 10%, 2-3 binge episodes/month • 8% weekly; 4% daily marijuana use (OSDUS, CAMH, 2003) • 8.9% physically assaulted in dating relationship past year • 11.9% females; 6.1% males ever forced into sexual intercourse (YRBSS, CDC, 2003) • 19% emotional abused (ADDHealth, Carver et al., 2003)
  14. 14. Points for Developmental Timing Developmental Tasks: –Emotional Autonomy –Behavioural Independence –Identity –Sexuality & Romantic Relationships –School Achievement & Career Planning
  15. 15. Stages of Change (Transtheoretical Model of Change; Prochaska, DiClemente, & Norcross, 1992)
  16. 16. Stages of Change
  17. 17. Change Targets: Motivation Motivational 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 trait • Non-”hard” confrontational yet directive • Responsibility for change rests with youth • Highlights 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
  18. 18. Motivational Interviewing Key Tool: Decisional Balancing Develop Ambivalence about Use • Tailored to stage-of-change • Discrepancy=motivation • Discussion on pros and cons of use (likes/dislikes) • Providing normative feedback • Imagine 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 teen • Teen presents the reasons for change
  19. 19. Change Targets: Pattern of Reinforcers • Behavioral 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; can’t 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)
  20. 20. Mediators: PTSD Symptomatology DSM- IV Symptom Classes: (1) 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)
  21. 21. 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 .23** .62** .32** Child Mal- treatment Trauma Symptoms Trauma Symptoms Dating Violence Dating Violence Emotional Abuse Emotional Abuse .25** .25** .38** .41**
  22. 22. 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 .23**.22* .75** .58** .20** .19** .52** Child Mal- treatment Dating Violence Dating Violence Trauma Symptoms Trauma Symptoms Anger Anger .25** .16*
  23. 23. 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)
  24. 24. 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 Prevention National Institute on Drug Abuse US Department of Education Office of Safe and Drug-Free Schools Surgeon General’s Office Office of Juvenile Justice and Delinquency Prevention
  25. 25. Conclusions • Need to consider utility of dual or multi-targeting targets for prevention based on demonstrated co-morbidities • Need for broader surveillance on dating violence behaviors • Need 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, PTSD • Need to understand better SES, gender, ethnicity/culture as moderators of outcome and adaptation to important subgroups e.g., child welfare youth • Need to demonstrate efficacious prevention through population surveillance