Treating and Preventing Adolescent Mental Health Disorders: Treating and Preventing Adolescent Mental Health Disorders

Book Title: Treating and Preventing Adolescent Mental Health Disorders > pp. [420]-[424]

UNDEFINED: AUTHORS

Treating and Preventing Adolescent Mental Health Disorders

Print ISBN 9780195173642, 2005
pp. [420]-[424]

in marijuana use had ended in 1992, and had climbed substantially by 1997, also raising congressional concern. The PDFA envisioned the new campaign operating with the government buying media time for the ads generated by PDFA, but the eventual legislation shifted control of the Campaign to the White House Office of National Drug Control Policy (ONDCP) and added other provisions. While most money was allocated to the purchase of time for advertising largely produced under the PDFA mechanism, the overall message strategy was designed outside of PDFA, and the advertising was to be complemented by public relations efforts in-cluding community outreach and institutional partnerships. Youth were addressed directly, but the campaign spent its resources equally on parent-focused messages, particularly encouraging parenting skills and monitoring of youth behavior.

The Congress funded an independent evaluation through National Institute on Drug Abuse (NIDA) which contracted with Westat and the Annenberg School for Communication at the University of Pennsylvania. The evaluation is ongoing, with the most recent report covering the first 2.5 years of the fully implemented campaign (Hornik et al., 2002). Pertinent results thus far are as follows.

•	Most parents and youth in the surveys recalled exposure to Campaign anti-drug messages. About 70 percent of both groups reported exposure to one or more messages through all media channels every week. The average (median) youth recalled seeing one television ad per week. In 2000 and the first half of 2001, less than 25 percent of parents recalled seeing a television ad every week; this increased to 40 percent in the second half of 2001 and to 50 percent in the first half of 2002.
•	There is evidence consistent with a favorable Campaign effect on some parent outcomes. Overall, there are favorable changes in three out of five parent belief and behavior outcome measures, including talking about drugs with children and monitoring of children. Moreover, parents who reported more exposure to Campaign messages scored better on four out of five outcomes after statistical controls were applied to adjust for the possible influence of other explanatory factors. In addition, parents who had more exposure the first time they were measured were more likely to talk with their children and do fun activities with their children subsequently. However, there was little evidence for Campaign effects on parents' monitoring behavior. That has been the focus of the parent Campaign and the one parent behavior most associated with youth nonuse of marijuana. In addition, there is no evidence for favorable indirect effects on youth behavior as a result of parent exposure to the Campaign.
•	There is also little evidence of favorable direct Campaign effects on youth. There is no statistically significant decline in marijuana use to date in the surveys undertaken for the evaluation (although the MTF study suggested that there was a small but significant decline in marijuana use between 2001 and 2002 at the 10th-grade level; Johnston, O'Malley, & Bachman, 2003a). However, there were no improvements in surveyed beliefs and attitudes about marijuana use between 2000 and the first half of 2002. Regardless of whether the trends were stable or showing a slight decline, there is no basis for attributing any youth changes to the Campaign specifically. Also, and of most concern, there is evidence for an unfavorable delayed effect of Campaign exposure from September 1999 through June 2001 on intentions to use marijuana and on other beliefs expressed 12 to 18 months subsequently.

Several hypotheses have been suggested to explain why a campaign might produce a boomerang effect. One comes from reactance theory (Brehm, 1966; Brehm & Brehm, 1981), an argument that youth react against adult threats to their freedom by feeling pressure to re-establish that freedom, including some pressure to engage in the forbidden behavior. The Campaign might represent such a threat. Another theory argues

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that the heavy dose of anti-drug messages carries a meta-message, the idea that many youth must be using drugs if there is so much attention being paid to them. Indeed, for this hypothesis there is some consistent evidence: youth more exposed to the campaign advertising are more likely to progress subsequently to a belief that most other kids are using marijuana, and that belief predicts subsequent initiation of marijuana use. Other hypotheses include the idea that ads that contain relatively weak arguments serve to stimulate strong counterarguments (J., 2003), or the idea that for some youth, the ads provide novel information and thus provoke curiosity about drugs.

Selective Intervention Programs

Selective intervention programs are designed to target groups at risk as subsets of the general population, such as children of drug addicts or children with school problems.

The Strengthening Families Program (Kumpfer & Alvardo, 1995) and the Focus on Families Program (Catalano, Gainey, Fleming, Haggerty, & Johnson, 1999; Catalano, Haggerty, Gainey, & Hoppe, 1997) represent examples of selective interventions for children with drug-abusing parents, with slightly different approaches. Strengthening Families contains three elements: a parent training component, a child skills training component, and a family skills training component. The goal of the parent training component is to reduce parental substance abuse and improve parenting skills. The goal of the child skills training component is to decrease the child's negative and socially unacceptable behavior. The goal of the family skills training component is to improve the family environment. Evaluations of efficacy so far have found short-term benefits for this intervention; longer-term studies have not been done.

Focus on Families is for parents receiving methadone maintenance. Here parents are taught skills for relapse prevention and coping to help improve their treatment outcomes, as well as family management and parenting skills. Preliminary data suggest that this program im proves treatment outcomes of parents and enhances their parenting skills.

Indicated Intervention Programs

Indicated intervention programs are those designed for groups already experimenting with drugs or engaging in other risky practices. To a great extent, indicated programs traverse the fine line between prevention and treatment interventions. The Reconnecting Youth Program (Eggert, Thompson, Herting, & Nicholas, 1995; Eggert, Thompson, Herting, Nicholas, & Dicker, 1994) is a prime example. This program is for adolescents in grades 9 to 12 who show signs of poor school achievement and the potential to drop out. The program teaches skills to build resiliency toward risk factors and to moderate early signs of drug abuse. It consists of several components, such as a personal growth class designed to enhance self-esteem, decision making, personal control, and interpersonal communications; a social activities and school bonding program to establish drug-free peer relationships; and a school system crisis response plan to address suicide prevention. Evaluations of this intervention have documented only short-term benefits, with long-term studies yet to be done.

Multilevel Intervention Programs

Multilevel intervention programs are typically ambitious combinations of the above intervention models. They include universal, selected, and indicated strategies gauged to the needs of the adolescent.

The Adolescent Transitions Program (Dishion & Kavanagh, 2000) is an example of a multilevel intervention designed to address the needs of families of young adolescents that present with a range of problem behaviors and diverse developmental histories. This ambitious program incorporates universal, selective, and indicated prevention components. The universal prevention intervention is in the form of a school-based family resource room to establish a venue for exchange between school professionals and fam

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ilies. The selective intervention is in the form of a family check-up that offers family assessment and support, and the motivation to change behaviors. The indicated intervention provides a menu of services that includes a brief family intervention, school monitoring system, parent groups, behavioral family therapy, and case management services.

SUMMARIES AND REVIEWS OF MODEL PREVENTIVE INTERVENTIONS

Over the past decade numerous efforts have been undertaken to identify and disseminate descriptive information about model preventive interventions. In the family-focused prevention area alone, for instance, at least 11 of these model intervention reviews have gained some currency (Metzler, Biglan, Rusby, & Sprague, 2001). Reviews of model preventive interventions typically include descriptions of selection criteria or rules of evidence applied and summaries of the intervention review process. Many also delineate salient characteristics of the types of programs that have proven to be effective. A major issue for the field is the variability in the rules of evidence and intervention selection criteria, with the level of scientific rigor applied ranging considerably.

Frequently, model interventions are classified by the level of supportive evidence for the intervention (e.g., exemplary or promising). Most reviews of interventions consider the level of evidence for a particular intervention; some, however, create categories of interventions and critically evaluate the evidence only for specified types of interventions. Table 19.2 summarizes selected reviews of particular evidence-based interventions; it does not include reviews of types of programs. Rather, these are included in the following summary of meta-analysis and reviews of outcome studies of interventions from the relevant literature. Although some of the reviews are focused exclusively on interventions designed to prevent substance use or abuse among youth, many include interventions that target other youth problem behaviors as well. All of the reviews selected for inclusion in Table 19.2 have critically evaluated at least some substance- related preventive interventions described in published reports. Included in Table 19.2 is an especially instructive “review of reviews” of particular family-focused preventive interventions (Meltzer et al., 2002).

THE FUTURE OF YOUTH PREVENTION PROGRAMS: NEW DIRECTIONS

Recently, prevention professionals have broadened the target of their interventions, extending beyond substance abuse to globally address the quality of youth development. Advocates of positive youth development approaches emphasize that efforts to address public health concerns by preventing youth problem behaviors must be pursued in concert with youth-related health promotion goals. The need to integrate prevention and youth-related health promotion—or positive youth development—has emerged as a consequence of the observation that problem-free youth are not necessarily fully prepared youth (Pittman, Irby, & Ferber, 2000). In keeping with this concept, several scholars (Eccles & Gootman, 2002; Flay, 2002; Lerner, 2001; Roth & Brooks-Gunn, 2002; Villarruel, Perkins, Bordon, & Keith, 2003) have cogently argued for the need for strategies and interventions that prepare young people to fully participate in school and career, by reducing the level of harmful or risk behaviors and building “external” developmental assets (e.g., support from parents, peers, teachers) along with “internal” assets (e.g., social competencies—see Scales, Benson, Leffert, & Blyth, 2000).

Community-based intervention researchers have underscored how difficult it is to accomplish substantial behavior change in large populations (e.g., Holder, 2002), in part because of natural tensions between researchers and community-based practitioners (Greenberg & Spoth, in press; Spoth & Greenberg et al., in press; Price & Behrens, 2003; Wandersman, 2003). This conclusion is consistent with earlier admonitions about ways in which prevailing economic, political, and social forces can perpetuate unhealthy behaviors such as problem drinking (Giesbrecht, Krempulec, & West, 1993). Many researchers agree that the key to address

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Table 19.2 Reviews of Particular Evidence-Based Interventions

Reference	Level of Intervention	Summary
Alvarado, Kendall, Beesley, & Lee-Cavaness, 2000	Family	This review entails “Two page summaries of family-focused programs which have been proven to be effective.The programs in this booklet are divided into categories based upon the degree, quality and outcomes of research associated with them” (p.vi). “Numerous criteria were utilized by the review committee to rate and categorize programs. The criteria included: theory, fidelity of the interventions, sampling strategy and implementation, attrition, measures, data collection, missing data, analysis, replications, dissemination capability, cultural and age appropriateness, integrity and program utility. Each program was rated independently by reviewers, discussed and a final determination made regarding the appropriate category” (p.vii).
Catalano, Berglund, Ryan, Lonczak, & Hawkins, 2002	Multiple	This review “Describes the findings from evaluations of positive youth development programs. The chapter highlights 25 well-evaluated programs and their results. Elements of the programs are described, including positive youth development constructs, social domains, and strategies.” (http://www.journals.apa.org/prevention/volume5/pre0050015a.html )
Center for the Study and Prevention of Violence, 2003	Multiple	The center “Has identified 11 prevention and intervention programs that meet a strict scientific standard of program effectiveness.The 11 model programs, called Blueprints, have been effective in reducing adolescent violent crime, aggression, delinquency, and substance abuse. Another 21 programs have been identified as promising programs.” (http://www.colorado.edu/cspv/blueprints /)
Developmental Research and Programs, 2000	Multiple	Communities that Care (CTC) is an integrated approach to positive youth development and the prevention of problem behaviors including substance abuse, academic failure, unplanned pregnancy, school dropout, and violence. This program is based on prevention science—social development theory—which aims to identify and reduce risk factors and promote protective factors in the development of problem behaviors among young people. (http://www.channing-bete.com/positiveyouth )
Drug Strategies, 1999	School	This assessment “is based on careful review of curriculum materials and other information provided by curriculum developers and distributors as well as evaluation reports on 14 curricula.Extensive research during the past two decades points to certain key elements of successful prevention curriculaassesses the extent to which curricula address these key areas” (p.1).
Eccles & Gootman, 2002	Community	“We considered reviews that included both programs for youth with a primary focus on prevention and programs explicitly focused on a youth development framework.Programs based on clinical theories of behavior change and sound instructional practices are effective at both reducing problem behaviors and increasing a wide range of social and emotional competencies. In addition, interventions in the field of mental health promotion use high evaluation standards. All evaluations included in both reviews used both control group comparisons, and the majority used random assignment. The high level of evaluation rigor obtained was understandably facilitated by the short-term nature of the programs, the integration of these programs into the school day, and the fact that program participation was more likely to be seen by participants as required rather than voluntary” (pp.148, 172).
Greenberg, Domitrovich, & Bumbarger, 2000	Multiple	“The goals of this report were toidentify universal, selective and indicated programs that reduce symptoms of both externalizing and internalizing disorders; summarize the state-of-the art programs in the prevention of mental disorders in school-age children; identify elements that contribute to program success; and provide suggestions to improve the quality of program development and evaluation.” (http://www.prevention.psu.edu/resources.html ) The scope of interest for this review included prevention programs for children ages 5 to 18 that produce improvements in specific psychological symptoms or in factors directly associated with increased risk for child mental disorders. Programs were excluded if they produced outcomes solely related to substance abuse, sexuality or health promotion or positive youth development.
Hansen, 1992	School	“Substance use prevention studies published between 1980 and 1990 are reviewed for content, methodology and behavioral outcomes.Studies were classified based on the inclusion of 12 content areas: Information, Decision-Making, Pledges, Values Clarification, Goal Setting, Stress Management, Self-Esteem, Resistance Skills Training, Life Skills Training, Norm Setting, Assistance and Alternatives. Comprehensive and Social Influence programs are found to be most successful in preventing the onset of substance use” (p.403).
Olds, Robinson, Song, Little, & Hill, 1999	Family	This study is a review of research that tested universal, selected, or indicated interventions that took place between the prenatal period and a child's fifth year (0–5) and examined outcomes indicative of either child behavioral adjustment problems or major parent or family risk factors (e.g., maternal mental health and use of substance; relationship disturbance).
Promising Practices, 2001	Multiple	“PPN [Promising Practices Network] has organized information on effective programs under six broad result areas that are associated with the well-being of children, youth, and families. For each of these results areas, one or more specific benchmarks have been identified.PPN provides a summary of each program that identifies key information about its effectiveness.We've included programs that meet a minimum level of evidence and are labeled as follows: (1) Proven—at least one credible, scientifically rigorous study that shows the program improves at least one benchmark; Promising—at least some direct evidence that the program improves outcomes for children and families.” (http://www.promisingpractices.net )
Roth, Brooks-Gunn, Murray, & Foster, 1998	Multiple	“We evaluate the usefulness of the youth development framework based on 15 program evaluations. The results of the evaluations are discussed and 3 general themes emerge” (p.423).
SAMHSA Model Programs, 2003	Multiple	Programs are evaluated according to 18 methodological criteria, three appropriateness criteria, and program descriptors for evaluating general substance abuse and treatment programs. “Individual scores from members of each reviewer team are compiled, together with their narrative descriptions of the review program's strengths, weaknesses, and major components and outcome findings. Summary scores from two parameters, Integrity and Utility, are then used to rank programs respectively on the scientific rigor of their evaluation and the practicality of their findings.” (http://modelprograms.samhsa.gov/pdfs/compmatrix.pdf )
Strengthening America's Families, 1999	Multiple	This Web site describes effective family programs for the prevention of delinquency. Programs for the prevention of delinquency and other negative outcomes are described and rated against a set of criteria as “Exemplary,” “Model,” or “Promising.” The Web site also contains a literature review and an organizational matrix of programs, arranged by type of prevention program (universal, selected, indicated). Available on-line at: http://www.strengtheningfamilies.org/html/modelprograms/mfppg1.html
U.S. Department of Education, 2001	School	“This publication provides descriptions of the 9 exemplary and 33 promising programs selected by the 15-member Expert Panel for Safe, Disciplined, and Drug-Free Schools in 2001.The task was to develop and oversee a process for identifying and designating as promising and exemplary programs that promote safe, disciplined, and drug-free schools. The seven criteria are: (1) The program reports relevant evidence of efficacy/effectiveness based on a methodologically sound evaluation; (2) The program's goals with respect to changing behavior and/or risk and protective factors are clear and appropriate for the intended population and setting; (3) The rationale underlying the program is clearly stated, and the program's content and processes are aligned with its goals; (4) The program's content takes into consideration the characteristics of the intended population and setting (e.g., developmental stage, motivational status, language, disabilities, culture) and the needs implied by these characteristics; (5) The program implementation process effectively engages the intended population; (6) The application describes how the program is integrated into schools' educational missions; (7) The program provides necessary information and guidance for replication in other appropriate settings” (pp.1–2).

SAMHSA, Substance Abuse and Mental Health Administration.

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doi:10.1093/9780195173642.003.0020