Reducing Toxic Stress and Promoting Young People s Behavioral Health: Communities That Care

Transcription

1 Reducing Toxic Stress and Promoting Young People s Behavioral Health: Communities That Care September 23, 2014 J. David Hawkins, Ph.D. Endowed Professor of Prevention Social Development Research Group University of Washington School of Social Work jdh@uw.edu

2 Research Support from: Funders National Institute on Drug Abuse National Cancer Institute Center for Substance Abuse Prevention National Institute on Child Health and National Institute of Mental Health Human Development National Institute on Alcohol Abuse and Alcoholism State Collaborators Colorado DHS Alcohol & Drug Abuse Division Illinois DHS Bureau of Substance Abuse Prevention Kansas Dept. of Social & Rehabilitation Services Maine DHHS Office of Substance Abuse Oregon DHS Addictions & Mental Health Division Utah Division of Substance Use & Mental Health Washington Division of Behavioral Health & Recovery 2

3

4 Prevention Logic To prevent a problem before it happens, the factors that predict the problem must be changed. 4

5 34 Years of Research Advances Longitudinal and epidemiological studies have identified predictors of many negative developmental outcomes as well as behavioral health.

6 N/A 6

7 Protective Factors (Social Development Strategy) 7

8 Prevalence Multiple Risks = Toxic Environment Prevalence of 30 Day Alcohol Use by Exposure to Risk and Protective Factors Six State Student Survey of 6th-12th Graders, Public School Students 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Number of Protective Factors 0 to 1 2 to 3 4 to 5 6 to 7 8 to 9 0% 0 to 1 2 to 3 4 to 5 6 to 7 8 to Number of Risk Factors

9 Cumulative Risk: Prevalence of Problems by Exposure to Risk Factors % depressive symptomatology deliberate self harm homelessness early sexual activity >=10 Risk factors Bond, Thomas, Toumbourou, Patton, and Catalano, 2000

10 34 Years of Prevention Advances Experimental trials have identified over 50 effective interventions for promoting behavioral health and preventing negative developmental outcomes. See

11 Wide Ranging Approaches Have Been Found To Be Efficacious

12 Mental Health Obesity Vehicle Crashes Unintended Pregnancy HIV STI Drug Use Violence Wide Ranging Approaches Have Been Found To Be Efficacious Prevention Programs/Policies 9. Community Based Skills Training/Motivational Interviewing 10. Cash Transfer for School Fees/Stipend 11. Multicomponent Positive Youth Development 12. Policies (eg., MLDA, Access to Contraceptives) P 13. Community Mobilization 14. Medical Intervention 15. Law Enforcement 16. Family Planning Clinic

13 The Seattle Social Development Project- A Test of Raising Healthy Children Seeks to promote bonding to school and family by increasing youths opportunities, skills and recognition for prosocial involvement at school and home. Target: All urban multiethnic children in experimental classrooms starting from Grade 1 through 6 (ages 6-12) or from Grade 5 through 6 (ages10-12). Funded by: The National Institute on Drug Abuse, Robert Wood Johnson Foundation, Office of Juvenile Justice and Delinquency Prevention, Burlington Northern Foundation 13

14 Raising Healthy Children In-Service Teacher Training Classroom management Interactive teaching Cooperative learning Parent Workshops Catch em Being Good Supporting School Success Guiding Good Choices Child Social, Cognitive and Emotional Skills Training 14

15 Effects by End of Grade 6: California Achievement Test Scores *p<.05 compared with controls; N = 548 to 551.

16 Effects by Age 18 Compared to Controls By age 18 Youths in the Full Intervention had less heavy alcohol use: less lifetime violence: less grade repetition 25.0% Control vs. 15.4% Full 59.7% Control vs. 48.3% Full 22.8% Control vs. 14.0% Full Full Intervention Control Late Tx Late Tx Full Intervention Control Grade Age

17 Effects By Age 21 Compared to Controls By age 21, full intervention group had: More high school graduates: More attending university: Fewer selling drugs: Fewer with a criminal record: 81% Control vs. 91% Full 6% Control vs. 14% Full 13% Control vs. 4% Full 53% Control vs. 42% Full Full Intervention Control Late Tx Late Tx Full Intervention Control Grade Age

18 Effects on Sexually Transmitted Infection Onset through Age 30 18

19 Prevalence Proportion in 3 Conditions Who Met Criteria for GAD, social phobia, MDE, or PTSD diagnosis at ages 24 and 27 30% 27% 26% Control 25% 20% 15% 21% 18%* 22% 15%* Late Full 10% 5% 0% Age 24 Age 27

20 Effects Through Age 33 Social Development Research Group Mental Health Disorders 50% 40% 30% Mental health disorder a 30% 25% 20% Major depressive episode Control Full Interv. 20% 15% 10% 10% 0% % a Includes major depressive episode, generalized anxiety disorder, social phobia, and PTSD. Shaded data points: p<.10 p<.05 Analyses control for having been born to a teen mother. 20

21 But Prevention approaches that do not work or have not been evaluated are more widely used than those shown to be effective. 21

22 The Challenge To increase use of tested and effective prevention policies, programs and practices while recognizing that communities are different from one another and need to decide locally what programs they use. 22

23 Snapple Fact #101 Young people in different communities are exposed to different levels of risk and protection. 23

24 Why a Place Based Approach? Communities Vary in Protection & Risks 24

25 A Place Based Approach Hypothesis: Local choice and implementation of evidence based programs to address widespread risks in the community will produce community wide effects on youth health and behavior outcomes.

26 Communities That Care Develops Capacity to Build a coalition of diverse stakeholders to achieve collective impact. Assess and prioritize for action- risk, protection, and behavioral health outcomes. Strengthen protection and address priority risks with effective preventive interventions. Sustain high fidelity implementation of preventive interventions to reach all those targeted. Measure progress and outcomes 26

27 CTC s Five Phases

28 CTC Trainings 1. Key Leader Orientation 2. Community Board Orientation 3. Community Assessment Training 4. Community Resource Assessment Training 5. Community Planning Training 6. Community Program Implementation Training 28

29 CTC Logic Model Adoption of Science-Based Prevention Community Collaboration for Prevention Appropriate Selection & Implementation of Tested, Effective Prevention Programs CTC Training & Technical Assistance CTC Coalition Functioning & Capacity Community Support for Prevention Community Norms Decreased Risk & Enhanced Protection Social Development Strategy Positive Youth Outcomes 29

30 Communities that Care Process and Timeline Process Measurable Outcomes Assess risk, protection and resources Implement and evaluate tested prevention strategies Increase in priority protective factors Decrease in priority risk factors Increase in positive youth development Reduction in problem behaviors Vision for a healthy community 6-9 mos. 1 year 2-5 years 4-10 years 30

31 Community Youth Development Study: A Test of Communities That Care 24 incorporated towns ~ Matched in pairs within state ~ Randomly assigned to CTC or control condition 5-year implementation phase 5-year sustainability phase Longitudinal panel of students ~ N=4,407- population sample of public schools ~ Surveyed annually starting in grade 5 31

32 Received six CTC trainings CTC Towns: Coalition of Stakeholders Collected data on local levels of risk and protection Prioritized risk and protective factors to address Implemented tested prevention policies and programs from menu 32

33 na

34 Communities Targeted a Variety of Risk Factors CTC Community RISK FACTORS Laws and norms favorable to drug use Low commitment to school x x x x x x x x x Academic failure x x x x x Family conflict X x x Poor family management x x x x Parental attitudes favorable to problem behavior Antisocial friends X x x x x x x Peer rewards for antisocial behavior X x Attitudes favorable to antisocial behavior X x x Rebelliousness X x x Low perceived risk of drug use x x x x 34

35 Selective After school Family Focused School-Based Number of CTC communities implementing effective programs Program All Stars Core Life Skills Training (LST) 2 4* 5* 5* Lion s Quest SFA (LQ-SFA) Project Alert Olweus Bullying Prevention Program - 2* 2* 2* Towards No Drug Abuse (TNDA) Class Action * Program Development Evaluation Training Participate and Learn Skills (PALS) Big Brothers/Big Sisters Stay SMART Tutoring Valued Youth Strengthening Families Guiding Good Choices 6 7* 8* 7 Parents Who Care Family Matters Parenting Wisely Total number of programs *Some funded locally (Fagan et al., 2009) 35

36 Numbers exposed to effective programs Program Type School-Based After-school * Family Focused Note: Total eligible population of 6 th, 7 th, and 8 th -grade students in was 10,031. * Includes PALS, BBBS, Stay SMART, and Tutoring programs (Fagan et al., 2009) 36

37 CTC Logic Model Adoption of Science-Based Prevention Community Collaboration for Prevention Appropriate Selection & Implementation of Tested, Effective Prevention Programs CTC Training & Technical Assistance CTC Coalition Functioning & Capacity Community Support for Prevention Community Norms Decreased Risk & Enhanced Protection Social Development Strategy Positive Youth Outcomes 37

38 CTC Logic Model Adoption of Science-Based Prevention Community Collaboration for Prevention Appropriate Selection & Implementation of Tested, Effective Prevention Programs CTC Training & Technical Assistance CTC Coalition Functioning & Capacity Community Support for Prevention Community Norms Decreased Risk & Enhanced Protection Social Development Strategy Positive Youth Outcomes 38

39 na 39

40 na

41 Effects of CTC on Incidence of Behavior Problems In the panel by grade 8, youth in CTC communities were 33% less likely to start smoking cigarettes 32% less likely to start drinking 25% less likely to start engaging in delinquent behavior than those from control communities. (Hawkins et al. 2009) 41

42 Effects of Communities That Care on Prevalence of Current Behaviors In the panel, in grade 8 youth in CTC communities were: 23% less likely to drink alcohol currently than controls. 37% less likely to binge (5 or more drinks in a row) than controls. Committed 31% fewer different delinquent acts in past year than controls. (Hawkins et al., 2009) 42

43 Sustained Effects One Year after Intervention Funding Ended In the panel, compared to controls, 10 th graders from CTC communities had: Lower levels of targeted risk factors. Less initiation of delinquent behavior, alcohol use, and cigarette use. Lower prevalence of past-month cigarette use. Lower prevalence of past-year delinquency Lower prevalence of past-year violence. Hawkins et al., 2012, Archives of Pediatrics and Adolescent Medicine

44 Sustained Abstinence through Grade 12 Never Used Alcohol p <.05 RR = 1.31 Hawkins et al., 2014 JAMA Pediatrics 44

45 Sustained Abstinence through Grade 12 Never Smoked Cigarettes p <.05 RR = 1.13 Hawkins et al., 2014 JAMA Pediatrics. 45

46 Sustained Abstinence through Grade 12 Never Engaged in Delinquency RR = 1.18 p <.05 Hawkins et al., 2014 JAMA Pediatrics. 46

47 Summary 8 years after CTC implementation and 3 years after study-provided resources ended: CTC continued to prevent the initiation of alcohol use, smoking, delinquency, and violence through 12 th grade. 47

48 Was that benefit worth the cost of CTC? 48

49 CTC Cost-Benefit Analysis: using WSIPP Software Tool Calculate Per Youth Cost of CTC Intervention Per Youth Cost = $556 over 5 years (2011 dollars) Calculate Per Youth Benefits Compare Per Youth Costs and Benefits ~ Net Present Value ~ Benefit-Cost Ratio Monte Carlo simulation methods ~ Investment Risk ~ Cash Flows 49

50 How Do Outcomes Lead to Monetary Benefits? Major avoided costs and increased revenues Direct Effects Indirect Effects Outcome: Initiation of Effect Size Criminal Justice System Costs Victimization Costs Linked Outcome Earnings Gain Health Care Costs Property Loss Delinquency 0.15 High School Graduation.39 (.09) 50

51 Benefit-Cost Analysis Summary: CTC Effects on Abstinence through Grade 12 Discounted 2011 dollars Criminal Justice System 1,000 Monte Carlo Simulations Victimization Earnings Health Care Property Loss CTC 12 th Grade Total WSIPP Adjustments to Effect Sizes * Benefits $897 $1,729 1,767 $83 $1 $4,477 $2,305 Participants (17) Taxpayers , Other 0 1,729 0 (100) 0 1, Other Indirect Costs ($556) ($556) * WSIPP halves effects when the program developer is involved in the trial as it was in the CYDS (Hawkins involved). 51

52 Benefit-Cost Analysis Summary: CTC Effects on Abstinence through Grade 12 Discounted 2011 dollars Criminal Justice System 1,000 Monte Carlo Simulations Victimization Earnings Health Care Property Loss CTC 12 th Grade Total WSIPP Adjustments to Effect Sizes * Benefits $897 $1,729 1,767 $83 $1 $4,477 $2,305 Participants (17) Taxpayers , Other 0 1,729 0 (100) 0 1, Other Indirect Costs ($556) ($556) Net Present Value $3,920 $1,749 Benefit Cost Ratio Investment Risk: % trials NPV > $0 100% 99% * WSIPP halves effects when the program developer is involved in the trial as it was in the CYDS (Hawkins involved). 52

53 CTC Discounted Cash Flows Over 50 Years Discount rate: 3.5% $250 $150 $50 -$ Years from Program Start 50 -$150 -$250 Years from Program Start 53

54 Summary Communities That Care is Cost-Beneficial even when effect sizes are reduced by 50% Summary indicators are favorable ~ Net present value: $1,749 ~ Benefit cost ratio: 4.23 ~ Low risk of negative investment return Largest share of benefits was from delinquency prevention Findings sustained from 8 th through 12 th grade 54

55 Cross-sectional Samples - CYDS Found no significant effects of CTC in reducing drug use or delinquency across 6 th, 8 th or 10 th grade from pre CTC (combined baseline to outcome ). Longitudinal analyses (grade 6 baseline to grade 10 four years later), found only one significant effect smokeless tobacco use. (Rhew et al., under review) 55

56 Why different findings? Limited power due to small number of communities? Repeated cross-sectional studies include a different population of students in the baseline sample compared to the follow-up sample. Inability to link data from individuals over time could reduce power to detect intervention effects. The student population at follow-up included students who moved to the community sometime after baseline. These students may have had limited exposure to the CTC system attenuating observed effects of CTC. 56

57 CTC in Pennsylvania Adopted as a statewide initiative in cycles of CTC training delivered. About 65 currently functioning CTC communities System of assessment & dedicated technical assistance to improve coalition functioning Opportunity to study CTC in a long-term largescale implementation under real-world conditions-developer not involved

58 Pennsylvania s CTC coalitions 2014

59 Cross-Sectional Samples Pennsylvania Data Cross-sectional quasi-experimental study of 98,000 students in 147 communities Used propensity score matching to minimize potential selection bias Found youth in CTC communities reported lower rates of risk factors, substance use, and delinquency than youth in similar non-ctc communities (7x as many as by chance) Communities using EBPs showed better outcomes on twice as many R/P factors and behaviors (14x as many as by chance) (Feinberg et al., 2007)

60 5 year Longitudinal Study of PA Youth % Change of CTC/EBP Youth Over Comparison Group 419 age-grade cohorts over a 5-year period: youth in CTC communities using EBPs had significantly lower rates of delinquency, greater resistance to negative peer influence, stronger school engagement and better academic achievement Delinquency Negative Peer Influence Academic Performance School Engagement Feinberg, M.E., Greenberg, M.T., Osgood, W.O., Sartorius, J., Bontempo, D.E. (2010). Can Community Coalitions Have a Population Level Impact on Adolescent Behavior Problems? CTC in Pennsylvania, Prevention Science.

61 How does CTC produce better outcomes? Communities That Care increases adoption of science based prevention by key community leaders. (Brown et al. 2013) Key leader adoption of a science based approach to prevention is the mechanism by which CTC leads to significant reductions in youth crime and drug use. 61

62 Adoption of a Science-Based Approach to Prevention No Awareness Awareness of prevention science terminology & concepts Use of risk and protectionfocused prevention approach as planning strategy Use of epidemiological data on risk and protection in prevention planning Selection of tested and effective interventions to address prioritized risk and protective factors Use of tested and effective interventions, collection of program process and outcome data, and adjustment of interventions based on data Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 62

63 Why do communities adopt science based prevention? CTC training is key to ensuring adoption of science based prevention and to effective functioning of coalition. (Gloppin et al. in press) 63

64 Challenge CTC training has been delivered live through 6 visits to each CTC community by a certified trainer over several months. This limits flexibility in scheduling workshops and makes providing the CTC workshops, refresher workshops, and training of new leaders and coalition members costly. It makes spreading CTC to a large number of communities difficult. 64

65 Solution The ectc Training and Implementation Support System. Component 1 Web streamed workshop series: Locally facilitated Content provided via brief embedded videos Activities ensure knowledge and skill acquisition and application 65

66 Benefit Web-streamed locally facilitated workshops make spreading CTC to many new communities feasible without requiring large numbers of travelling certified CTC trainers. 66

67 J. David Hawkins, Ph.D. Endowed Professor of Prevention 67

68 End of Powerpoint -extra slides below here. 68

69 Adoption of Science- Based Prevention is Key Adoption of Science-based Prevention (2004) b = 1.11**, R 2 =.42 b = -.05*, R 2 =.39 CTC Training and Technical Assistance (2003) Indirect Effect: b = -.06*, 96% variance explained b = -.561*, R 2 =.47 Student Problem Behavior (2007) * p <.05 ** p <.01

70 CTC Implementation Worldwide United States Canada Australia Netherlands Germany United Kingdom Colombia Sweden The CTC Survey is being used or adapted in Brazil, Chile, India, and Croatia.

71

72 Additional Assumptions Participant age: 18 (12 th Grade) Benefits stream ends: Crime to age 59 Earnings to 65 Health care costs to 100 Property losses to 100 Deadweight cost of taxation: Included in model at 50% Discount rate: 3.5% (range: %) Results expressed in: Discounted 2011 dollars 72

73 To what extent does participation in CTC training workshops increase use of science-based prevention reported by community leaders? 73

74 Reported stages of adoption of science-based prevention in CTC Communities by trained leaders v. leaders not trained 62% 58% 44% 17% 21% 13% 74

75 Analysis Multi-level models to account for nested data: 4407 Students 24 Communities 12 Matched Pairs Adjustment for student and community characteristics Students: Age, race, ethnicity, parental education, religious attendance, rebelliousness. Community: Student population, % of students receiving free/reduced price school lunch. Missing data approach: 40 imputed data sets Results averaged using Rubin s rules