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Preventing Health Risk Behaviors Strategies for Preventing Youth Risk Behaviors Conference Bethesda,

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The Incredible Years Series. Life Skills Training. Multisystemic Therapy. II. Effective Programs. Big Brothers/Big Sisters Mentoring. Midwestern Prevention Project ... – PowerPoint PPT presentation

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Title: Preventing Health Risk Behaviors Strategies for Preventing Youth Risk Behaviors Conference Bethesda,


1
Preventing Health Risk Behaviors Strategies for
Preventing Youth Risk Behaviors
Conference Bethesda, May 22, 2008
  • Delbert S. Elliott
  • Director, Center for the Study and Prevention of
    Violence
  • Institute of Behavioral Science
  • University of Colorado

2
The Public Health Approach to Prevention/Intervent
ion
  • What risk/protective factors are targeted?
  • What are the characteristics of the
    individual/population to be served ?
  • Which evidence-based programs address these
    risks/protective factors for this population?
  • What is the delivery capability of this/these
    program(s)?
  • What does the program/intervention cost?
  • What is necessary for a quality/high fidelity
    implementation?

3
Strong Risk Factors for Serious Offending at Age
15-25 (r) Early (Age 6-11) Late (Age12-14)
  • Weak Conventional Ties (.39)
  • Antisocial Peers (.37)
  • Gang Member (.31)
  • General Offenses (.38)
  • Substance Use (.30)

4
Moderate Risk Factors for Serious Offending at
Age 15-25 (r) Early (Age 6-11) Late (Age12-14)
  • General Offenses (.26)
  • Gender (Male) (.26)
  • Low Family SES (.24)
  • Antisocial Parent (.23)
  • Aggression (M) (.21)

5
Weak Risk Factors for Serious Offending at Age
15-25 (r lt.20) Early (Age 6-11) Late
(Age12-14)
  • Aggression (Males)
  • School Attitude/Performance
  • Parent-Child Relations
  • Psychological Conditions
  • Gender (Male)
  • Neighborhood Disorganization
  • Neighborhood Drugs/Crime
  • Antisocial Attitudes/beliefs
  • Problem Behavior
  • IQ
  • Broken Home
  • Low Family SES
  • Parental Abuse
  • Substance Use
  • Psych Condition
  • Hyperactivity
  • Poor P-C Relations
  • Weak Social Ties
  • Problem Behavior
  • Exposure to TV Viol.
  • Poor Sch Performance
  • Low IQ
  • Other Family Traits
  • Dishonesty
  • Broken Home
  • Parent Abuse/Neglect
  • Antisocial Peers

6
Protective Factors Evidence of Buffering Risk
  • Individual
  • Commitment to Moral Action
  • High IQ
  • Positive Social Orientation
  • High Academic Achievement
  • School
  • Commitment/Bonding to School
  • Source Youth Violence A Report of the Surgeon
    General

7
Effective and Ineffective Strategies
8
Effective Strategies Meta Analyses
  • Individual-Level Interventions
  • Self Control/Social Competency
  • Individual counseling
  • Behavioral Modeling/Modification
  • Multiple Services
  • Restitution with Probation/Parole
  • Wilderness/Adventure
  • Methadone Maintenance
  • Only with cognitive-behavioral methods (Wilson
    et al., 2001)
  • Only with non-institutionalized juvenile
    offenders (Lipsey and Wilson, 1998)

9
Effective Strategies Meta Analyses, Contd
  • Contextual (family, school and community)
  • School Discipline Management
  • Normative Climate Change
  • Classroom/Instructional Management
  • Reorganization of Grades, Classes
  • Teaching Family Model
  • Community Residential
  • Effective only with institutionalized juvenile
    offenders

10
Ineffective/Harmful Strategies
  • Scare Tactics
  • Punitive Practices
  • Developmentally Premature Strategies
  • Indicated Strategies More Cost Effective than
    Universal Strategies
  • Behavior Modification Strategies Often Lack
    Sustainability

11
Effective Programs
12
Standard for Certifying Programs as Effective
  • Experimental Design/RCT
  • Statistically significant positive effect
  • Effect sustained for at least 1 year post-
    intervention
  • At least 1 external replication with RCT
  • RCTs adequately address threats to internal
    validity
  • No known health-compromising side effects
  • Adapted from Hierarchical Classification
    Framework for Program Effectiveness, Working
    Group for the Federal Collaboration on What
    Works, 2004.

13
Hierarchical Classification
  • I. Model Meets all standards
  • II. Effective with Reservation Internal rather
    than external RCT replication(s)
  • III. Promising Lacks any RCT replication
  • IV. Inconclusive Contradictory findings or
    non-sustainable effects
  • V. Insufficient Evidence No evaluation or weak
    designs
  • VI. Ineffective Meets all standards but no
    significant effects

  • VII. Iatrogenic Effective, but with harmful
    effects
  • Adapted from Hierarchical Classification
    Framework for Program Effectiveness, Working
    Group for the Federal Collaboration on What
    Works, 2004.

14
Defining Evidence-Based
  • Programs classified as Model, Effective, or
    Promising on Federal Hierarchy
  • Consistently positive effects from Meta Analyses
  • Only Model programs should ever be taken to scale

15
Federal Working Group Classification of Top
Programs on Other Lists
  • Ctr. For MH Services Effective (14/34)
  • Most have not yet been rated on FWG standard
  • NREPP Model Effective (18/21)
  • Mod-4 Effec-16 Prom-16 Incon/Insuff- 64
  • NIDA Effective (20/21)
  • Mod- 10 Effec-25 Prom- 25 Incon/Insuff- 40
  • Blueprints Model (11/11)
  • Mod- 27 Effec- 64 Prom- 9 Incon/Insuff- 0

16
Federal Working Group Classification for Top
Programs on Other Lists
  • OJJDP-Title V Exemplary (33/40)
  • Mod- 9 Effec- 30 Prom- 15 Ineff/Incon- 45
  • OSDFS Exemplary (9/9)
  • Mod- 11 Effec- 23 Prom- 33 Ineff/Incon- 33
  • HAY Level 1 (12/12)
  • Mod-25 Effec- 30 Prom- 0 Ineff/Incon-42

17
Antisocial Behavior, Violence, Drug and
Delinquency Prevention Programs Overview
  • Most Programs Have No Credible Evaluation
  • Those With Credible Evaluations
  • Most Dont Work
  • 35 to 40 Clearly Work or Have Promise
  • A Few Appear to be Harmful
  • Some Model Programs Dont Have Capacity to Go to
    Scale
  • Center for the Study and Prevention of Violence

18
I. Model Programs
  • Functional Family Therapy
  • The Incredible Years Series
  • Life Skills Training
  • Multisystemic Therapy

19
II. Effective Programs
  • Big Brothers/Big Sisters Mentoring
  • Midwestern Prevention Project
  • Multidimensional Treatment Foster Care
  • Nurse Family Partnership
  • Project Towards No Drug Abuse
  • Promoting Alternative Thinking Strategies

20
II. Effective Programs, Contd
  • Cognitive Behavior Therapy for Child
  • Sexual Abuse
  • Strengthening Families
  • Athletes Training and Learning to Avoid Steroids
  • Brief Strategic Family Therapy
  • Guiding Good Choices

21
Source of Benefits from Prevention Programs
  • 38 of reduction in cocaine use from reduced use
    by participants
  • 44 positive spillover to friends and associates
    use
  • 17 these reductions from more effective
    enforcement with the shrinking market
  • Caulkins et al., 1999

22
Feasibility Example
  • Cost to provide every student in U.S. a model
    drug prevention program like LST is 550 million
    per year
  • Current national drug control spending is
    approximately 40 billion per year
  • This represents 1.5 of the current drug control
    spending

23
Tentative Commonalties Among Effective
Programs/Interventions
  • Sound Theoretical Rationale/Strong Risk Factors
  • Parent Effectiveness Training (Early Pgms Only)
  • Prevention Pgms Long-term (multi-year)
  • Intervention Pgms Intense, Clinical
  • Multi-modal and Multi-Contextual
  • Building Competency/Skill Development Strategy
  • Cognitive/Behavioral Delivery Techniques
  • Outside Institutional Settings
  • Capacity for Delivery with Fidelity

24
Benefit-to-Cost Ratios Selected EB (Blueprint)
Programs
  • Program Ratio Outcome
  • FFT 13.25 Crime
    reduction
  • LST 25.61 Drug
    reduction
  • MPP 5.29 Drug
    reduction
  • MST 2.64 Drug
    reduction
  • MTFC 10.88 Crime reduction
  • NFP 2.88 Crime
    reduction
  • Washington Institute for Public Policy (2004)

25
Benefit-to-Cost Ratios Selected Other Programs
  • Program Ratio Outcome
  • DARE 0.0
    None
  • Boot Camps 0.0 None
  • Head Start 0.23 None
  • Even Start 0.0
    None
  • Healthy Families 0.34 None
  • Scared Straight -203.51 Increases
    crime
  • Washington Institute for Public Policy (2004)

26
Annual Taxpayer Costs Benefits Forecast with
Moderate Portfolio of Evidence-Based Programs
27
Overcoming Barriers to Widespread Dissemination
28
Why Are We Not Implementing EB Violence
Prevention Programs?
  • Its hard to sell prevention- the focus
    typically is on improving responses to problem
    behavior
  • Programs not addressing strongest risk/protective
    factors or clusters
  • Confusion about standard for EB certification
  • Politics and parochial judgment often trump
    research
  • Increasing professional resistance to EB
    programs/practices
  • Failure to implement with fidelity

29
Professional Resistance
  • I particularly enjoyed your most recent article
    warning about the potential tyranny of
    evidence-based practices … I think you
    underplayed the possibility that an emphasis on
    such programs can inadvertently undermine rather
    than enhance school-wide reform efforts. …there
    is virtually no evidence that evidence-based
    practices contribute to overall school
    effectiveness, as data on such an issue are never
    gathered.
  • Unidentified well-respected scientist, Enews,
    August, 2007 (Vol 11, 11)

30
NREPP What is Evidence-Based?
  • One concern is that too much emphasis on EBPs
    may in some cases restrict practitioners from
    exercising their own judgment to provide the best
    care for individuals. For this reason, many
    organizations have adopted definitions of EB
    practice that emphasize balancing the
    scientific with the practical.

31
Impact of Unsafe Schools on Health and Academic
Performance
  • Poorer Student Health
  • Higher Rates of Dropout
  • Lower Test Scores
  • Smaller Gains in Academic Performance over time
  • Controlling for grade in school, race/ethnic
    composition, subsidized meals, average parent
    education, ESL students

32
Conclusions
  • We Need A Uniform Scientific Standard For
    Certifying Evidence-Based Programs
  • Existing Federal Lists Provide Some Guidance, But
    Programs Other Than Those In The Top Category Are
    Often Problematic
  • EB Program Should Be Selected For Its Known
    Effect On Particular Risks Protective Factors
    For Specific Groups
  • If You Decide To Use A Program Not Certified as
    EB, You Must Commit To Evaluating It
  • Do Not Use Any Program Found to Be Ineffective or
    Harmful
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