# Presentation: 922016

## PREVENTION RESEARCH2001

## PREVENTION RESEARCH BRANCH

- The Staff:
-   Liz Robertson, Ph.D., Chief
-   Susan David, M.P.H., Deputy Chief
-   Kathy Etz, Ph.D.
-   Eve Reider, Ph.D.
-   Larry Seitz, Ph.D.
-   Liz Cooper, Branch Secretary

**Notes:**
I’d like each of the excellent PRB staff members to stand as I say your name.
  Liz Robertson, Ph.D., Chief
  Susan David, M.P.H., Deputy Chief
  Kathy Etz, Ph.D. 
  Eve Reider, Ph.D.
  Larry Seitz, Ph.D.
  Liz Cooper, Branch Secretary

## RESEARCH OBJECTIVES

**   ****Prevent initiation of drug use;  **
**   ****Prevent the progression of     ****	****drug use among those who use;**
**   ****Prevent drug-related HIV ****	****infection****.**

**Notes:**
Our research objectives are to:

Prevent initiation of drug use;
Prevent the progression of drug use among those who use;
Prevent drug-related HIV infection.

##  Support Extramural Research

**  ****Efficacy Studies**
**  ****Effectiveness Trials**
**  ****Services Research **
**  ****Methodology Studies**

**Notes:**
NIDA supports an extramural drug abuse and HIV prevention program that includes: 

Randomized control group design Efficacy studies of theory-based Universal, Selective, and Indicative Interventions;

Effectiveness trials of proven interventions in real world settings with defined populations;

Services research studies – on topics related to the organization, management, and financing of prevention services, and;

Methodology studies that examine research designs, measurement, and analytic procedures specific to multi-level interventions.

## PREVENTION SCIENCE

**Epidemiology**
**Origins and pathways to drug abuse**
**Theories**
**Research evidence that prevention programs do work**

**Notes:**
Prevention science builds on
the strong platform of epidemiology research that has already and continues to be built by the ERB
Data on origins and pathways to drug abuse including what some call risk & protective factors and others call resiliency & vulnerability factors.  
Some of these factors can be modified through intervention, others cannot, but I’ll talk about that in a few minutes
Theories that posit underlying processes and mechanisms across the life span that contribute to drug abuse and its prevention
Research evidence that prevention programs do work, that is they can be efficacious, effective, and cost effective

## WHERE WE ARE

_**20 years of research found**_**:**
**Modifiable risk & protective factors**
**Points of vulnerability **
**Some basic prevention principles**

**Notes:**
 SO WHERE WE ARE after more than Twenty Years of Prevention Research:
Identified modifiable risk & protective factors for targeting through prevention programming.
Identified developmental and social transitions that can result in vulnerability, to the precursors of drug abuse or drug abuse itself. 
This allows our researchers to target specific vulnerable period with appropriate intervention components.
Finally, we’ve elucidated some basic prevention principles, which I’m not going to talk about, except to say that we are currently updating the “Red Book” .

## RESEARCH EXPANSION  1996 to 2000

| GRANTS BY COMPONENTS |  |
| --- | --- |
| Components | % Change 1991-1995 to 1996-2000 |
| Multi-component | 180% |
| Family | 200% |
| School | 100% |
| Work | 100% |
| Clinic | 600% |
| Media | 1000% |

**Notes:**
Research Expansion 1996 to 2001
Over the last five years we’ve been moving away from a portfolio characterized by primarily universal, school based interventions, 
to one that includes more component areas and as you will see, a broader range of populations.  
For example, while the school-based portfolio has doubled, it has mainly been in interventions for higher risk groups and individuals.  
Also with the recognition that consistency of prevention message across domains is extremely important we are moving to more multi-component programs.  
Many of these include a family component in recognition of the fact that family plays an early and continuing role in the socialization process, from infancy through late adolescence.
Other new, exciting components are being developed for media and clinical settings 
and we are working hard to jumpstart the workplace area.

## RESEARCH EXPANSION  1996 to 2000

| GRANTS BY TYPE |  |
| --- | --- |
| Components | % Change 1991-1995 to 1996-2000 |
| Centers | -50% |
| Training | 200% |
| Methodology | -33% |
| Services | 160% |
| Etiology | -300% |
| Epidemiology | -100% |

***RESEARCH EXPANSION******  ******1996 to 2000***

**Notes:**
Over the evolution of the branch, we have had a number of epidemiology and etiology grants.  Over time these have moved to the ERB. 
 At the same time we’ve been working hard to build the next generation of prevention researchers through training grants.
As well as to begin developing the prevention services portfolio.

## LEVELS OF RISK

**Universal – all persons in a particular group**
**Selective – groups at high risk**
**Indicated – individuals at high risk**

**Notes:**
You’ve all seen these definitions before, but just by way of review, we have adopted the IOM classification for prevention trials
For example at the 
Universal  level an intervention might target all children in a school
Selective level  children growing up in areas with high drug availability and at the 
Indicated level children who have already started experimenting with drugs, but not at a clinically diagnosable level.

Next slide shows percent change in these, as well as, a few other population or audience related categories

## RESEARCH EXPANSION  1996 to 2001

| GRANTS BY Level of Risk |  |
| --- | --- |
| Components | Change from 1996 - 2001 |
| Universal | 113% |
| Selective | 375% |
| Indicated | 225% |
| Tiered | 100% |
| Special populations | 58% |
| Gender specific | 200% |

**Notes:**
Research expansion 1996 to 2001
While we’ve continued to grow the universal portfolio, mainly in the areas of family and media,
 we’ve been targeting the growth of selective and indicated interventions. 
New area emerging from the field is tiered interventions-
that is interventions that that initially target a universal population and then identify those in need of selective level intervention and from there those in need of indicated level interventions.
We’ve developed a concentrating on gender specific intervention.  This increase indicates only those grants that particularly target one gender, 
we have many more that are doing gender comparison work
 Finally you may be wondering why we have such a small increase in special population grants, this is because this has always been a focus of the branch and we have many many grants that address African Americans, Hispanic, and Native American,

## RESEARCH EXPANSION  1996 to 2000

| SBIR PROGRAM |  |  |  |
| --- | --- | --- | --- |
| FY | GRANTS | CONTRACTS | TOTAL |
| 1996 | 7 | 0 | 7 |
| 1997 | 7 | 0 | 7 |
| 1998 | 11 | 2 | 13 |
| 1999 | 11 | 7 | 18 |
| 2000 | 13 | 10 | 23 |

**Notes:**
We’ve been using the small business innovative research grants and contracts  programs to build the prevention infrastructure
through getting our researchers to team with small businesses to produce and test research based materials, training modules, etc.  
Making these materials available is one avenue to developing sustainable preventions programs.  

## THUS, CURRENT FOCI..... 

** ****Broadening the components of ****	****intervention **
**  ****More multi-component programs**
**  ****More selective and indicated level ****	****programs**

**Notes:**
THUS, CURRENT FOCI...Seeing a more toward 
Broadening in the repertoire of program components
More programs with multiple components that present compatible messages, skills, etc.
Heavier concentration on developing interventions for those more at risk for subsequent drug abuse.

## THUS, CURRENT FOCI..... 

**  ****Early childhood through ****	****adulthood**
**  ****More independent replications**
**  ****More meta-analyses**

**Notes:**
THUS, CURRENT FOCI...

In addition to those areas highlighted in the tables, we have also been moving forward in broadening the portfolio to cover the life span.
 We have also been supporting more independent replications of interventions to establish effectiveness without primary involvement with the program designer or original researcher.
 and we’ve been support meta-analyses to develop a better understanding  of what program components are being used at the community level
And which have the greatest effects.

## THE BOTTOM LINE...

** ****In five years,**
**	****	****	****a **_***100%***_*** increase in ******	******	******	******grants***

**Notes:**
The bottom line in terms of the portfolio is 
that over the past 5 years we have doubled the number of grants we support 
and that the breadth and reach of the grants has also increased.

## SNAPSHOTS OF SELECTED FINDINGS

**Notes:**
SNAPSHOTS OF WHAT WE HAVE LEARNED
Factoids

## FINDINGS ON PROGRAM COMPONENTS

**Parents who smoke can lower the risk of smoking among their children by engaging  in anti-smoking socialization (Jackson, et al., 1997).**

**Notes:**
FINDINGS ON PROGRAM COMPONENTS

We know from epi data that children whose parents smoke have a 4-6 times greater chance of smoking.  
From the prevention research we’re found that even among parents who do smoke they can significantly lower the risk of smoking among their children by engaging  in anti-smoking socialization, 
such setting rules about handling tobacco products, smoking, andetablishing and enforcing consequences (Jackson, et al., 1997).

## FINDINGS ON PROGRAM COMPONENTS

**Intervening as early as grade one to decrease aggression and increase academic success substantially reduces subsequent substance abuse, depression and anti-social behavior (Ialongo, et al., 1999).**

**Notes:**
FINDINGS ON PROGRAM COMPONENTS
There is an increasing body of knowledge indicating that early interventions, especially with children at heightened risk for a constellation of negative outcomes and the potential for a life trajectory toward drug abuse, produce very successful outcomes.
For example, this long term follow-up study began in first grade had early effects in  decreasing aggression and increasing academic success 
Long-term results include substantial reductions in substance abuse, depression and anti-social behavior (Ialongo, et al., 1999).
Thus, even children with early behaviors that may foreshadow conduct problems can be helped if intervened with early enough.

## FINDINGS ON  AUDIENCE

**Gender significantly affects drug offers and types of offers (Moon, et al., 2000).**

**Notes:**
FINDINGS ON  AUDIENCE (Gender and Ethnicity)
Knowledge is emerging on factors such gender and ethnicity that are important for the adaptation of programs.
For example, gender significantly affects drug offers and types of offers;
Compared to females, males are more at risk for offers at a younger age and	
offers are more likely to come from parents and other males (Moon, et al., 2000).
Gender differences have relevance for both the underlying processes of interventions and the ultimate outcomes.

## FINDINGS ON  AUDIENCE

**Programs adapted to address the needs of specific ethnic audiences have greater effects in reducing substance use than universal non-adapted programs (Botvin, et al.,1997).**

**Notes:**
FINDINGS ON  AUDIENCE
Intervention developed for white suburban populations, such as LST, have been found to be quite effective with inner city ethnic populations, however
When these programs are adapted to address the specific needs and identity of ethnic audiences, they have even greater effects in reducing substance use.

## FINDINGS ON PROGRAM IMPLEMENTATION

**Providing accommodations to families helps to attract and retain them in preventive interventions (Spoth, et al., 1999).**

**Notes:**
FINDINGS ON PROGRAM IMPLEMENTATION
Similar to findings in treatment, making accommodations such as,
scheduling flexibility,
low time demand, 
babysitting, 
transportation, 
and personal contacts
helps to attract and retain families in interventions (Spoth,  et al., 1999).

## FINDINGS ON PROGRAM IMPLEMENTATION

**Grouping anti-social youth in interventions can lead to unintended negative effects such as increases in substance use and violence (Dishion et al., 1999).**

**Notes:**
FINDINGS ON PROGRAM IMPLEMENTATION
Finally, grouping anti-social youth in interventions can lead to unintended negative effects such as increases in substance use and violence (Dishion et a., 1999).
 in general the mechanisms that appear to cause these outcomes are subtle exchanges among group members that may not be apparent to the implementer.
But the important point here is that blended groups of strong pro-social youth and youth with problems, provides the best opportunity for positive outcomes.

## Slide 22

**Notes:**
The key to were we want to see the field of prevention go is to understand individuals within their contexts
over time and 
across the course of the development.
Thus for the child 	
starting in very early childhood the family is most important context, so interventions would concentrate on that context, 
then important contexts expand to include the school in the elementary years
The peer group in the middle school years and
Work in late adolescence and early adulthood  
These then become important targets for prevention components

## ROLE OF MODIFIERS 

**MODERATORS**

**MODIFIABLE **
**RISKS**

**INTERVENTION**

**Notes:**
ROLE OF MODIFIERS 
Moderators are fixed or virtually unchangeable factors:
Such as age, gender, ethnicity, and SES.
However, they have an effect on modifiable risk factors (recall the examples on gender and ethnicity).
Modifiable risks are those factors that can be changed through intervention.
Transitions are often looked at as points of vulnerability-(e.g., elementary school to middle school, middle school to high school). 
These are important intervention points because they signal the emergence of  biological, social, and cognitive issues that make the individual more susceptible to both positive and negative experiences.
Interventions then target risk factors, general at these points of vulnerability or transition.

## EARLY CHILDHOOD

**MODIFIABLE **
**RISKS**

**INTERVENTION**

**Inability to ****	****share**
**Inappropriate ****	****parental ****	****expectations**
**Inconsistent ****	****discipline**

**Child social ****	****practice**
**Early ****	****education**
**Parent skill ****	****training**
**       ****	****	****	**** ****	****	****	**

**Notes:**
EARLY CHILDHOOD

For example in early childhood, risks that may lead to later problems and are precursors of substance abuse include some of the child’s own behavior and the parents behavior.
From this list of modifiable risk factors, an intervention could target inconsistent discipline through parent skill training that teaches parents how to establish rules and consistently maintain developmentally appropriate consequences that will attached to the development of prosocial behavior
 In fact you will see that parent behavior remains  is important throughout the course of development.  

## ELEMENTARY SCHOOL AGE

**MODIFIABLE **
**RISKS**

**INTERVENTION**

**School transition**
**Teacher rules &****	****expectations**
**Lack of parental ****	****involvement**

**Organized ****	****classroom ****	**
**Consistently ****	****applied rules**
**Parent/teacher ****	****communication****       ****	****	****	**** ****	****	****	**

**Notes:**
ELEMENTARY SCHOOL AGE
The transition to elementary school is major because not only is the child outside the home or day care setting for most of the day, 
there are very specific performance demands placed on the child from the school.
Parent involvement because critical for most children in making a successful transition
Helping parents to learn how to become involved and assertive in communicating with school personnel as well as providing support to their child in their academic challenges is a predictor of school success

Intervention
Child social practice
Early education
Parent skill training

## MIDDLE SCHOOL AGE

**MODIFIABLE **
**RISKS**

**INTERVENTION**

**Shy/aggressive ****	****behavior**
**School****	****failure**
**Problem ****	****behavior**
**Poor parental ****	****monitoring**

**Social competence**
**Academic skills**
**Prosocial ****	****opportunities**
**Parent skills**

**Notes:**
MIDDLE SCHOOL AGE
This is perhaps the most critical transition with regard risk for initiation of substance use 
As the child enters the middle school, expectations for academic productivity increase at the same time that social pressures, especially those to conform,  become much more demanding.
Helping children over these hurtles, while providing them with pro-social opportunities is protective. 

## ADOLESCENCE

**MODIFIABLE **
**RISKS**

**INTERVENTION**

**Anti-social ****	****peer**
**Lack of school ****	****commitment**
**Family conflict**

**Social & ****	****academic skills**
**Refusal skills**
**Parent training**
**Family therapy**
**       ****	****	****	**** ****	****	****	**

**Notes:**
ADOLESCENCE
Finally, in adolescence, especially among those youth who have failed academically or have social problems,  there is often a tug of war between parents and peers.
 Providing social, academic, and refusal skills training can remediate some of these problems and help the adolescent to deal more proactively with peers and pro-socially with family members.

## NEW DIRECTIONS

**CROSSING THE GREAT DIVIDE**

## SELECTIVE AND INDICATED  POPULATIONS

** ****Clinical populations**
**Externalizing disorders**
**Internalizing disorders**
** ****Multi-risk children and families**

**Notes:**
I’m going to address four areas
SELECTIVE AND INDICATED  POPULATIONS
Clinical populations, such as children with disorders associated with subsequent drug abuse problems
Externalizing disorders
Internalizing disorders

Multi-risk children and families, such as children in foster care and families where one or more adults is a substance abuser.

## HIV PREVENTION

**Primary prevention **
**Selective populations**
**Indicated populations**

**Notes:**
HIV PREVENTION
  Increase portfolio of HIV prevention program components:
 Primary prevention (e.g. school health)
 Selective and indicated populations (e.g. homeless, and homosexual and bisexual youth) 

## BASIC PREVENTION 

**Next generation of research:**
**  ****What works**
**  ****For whom and **
**  ****Under what conditions**

**Notes:**
The next two areas represent the major areas of growth for the Branch
BASIC PREVENTION science is an effort 
Move beyond efficacy and effectiveness trials to next generation of research, i.e.  studies of intervention components to understand:
  What works
  For whom and 
  Under what conditions
The answers to these questions are central issues for communities interested in tailoring programs to their own needs, or crossing the great divide.
To this end we have developed the RFA Alan mentioned this morning and Dick mentioned yesterday and to date we have 28 serious expression of interest in applying.
These are not easy questions to address because of the lack of uniformity in prevention programming across the country

## PREVENTION SERVICES

** ****Existing systems for prevention**
** ****Funding sources**
** ****Program selection**
** ****Cost-benefits/effectiveness **
** ****Service availability, access, and    ****	****delivery**

**Notes:**
PREVENTION SERVICES
Which brings us to the opposite end of the spectrum, where we are pushing very hard to answer questions that will help in developing sustainable, research-based prevention.
Prevention is very different from treatment in that there are not clinics, credentialing of practitioners, third party payers and so forth.
However, many of our best researchers are working on aspects of these issues that we believe that this will position us to move into developing Prevention Trials Models
These efforts are as varied as	 
developing a registry of research-based prevention interventions, 
to defining levels of community readiness for prevention,
to examining the diffusion from the state to the local level of the risk and protective model of Hawkins et al. , 
to developing larger scale projects using existing service systems for the implementation of research based prevention program components.

Together they add up to what we envision as a schema for promoting and studying the spread of research based programs.  

This appears to be quite consistent with the growing consensus in the field about the concept of using existing  systems to reach populations with prevention services, which was discussed only recently at a think-tank sponsored by Robert Wood Johnson.

## GO  PREVENTION!

- Prevention!

- Go Prevention!

**GO  PREVENTION!**

- Go

- Go Prevention!

- Go Prevention!

- Go Prevention

- Go Prevention

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