Background: Substance Use Prevention Programs Targeting Youth At Risk
Substance use is one of today’s most challenging health and social problems. Further, it is more pervasive in the United States than in any other industrialized nation. Early involvement with any drug is a risk factor for later drug use and criminal activity, and the more severe the early involvement, the greater the risk that antisocial behaviors will emerge in the future. Early use of alcohol, tobacco, and other drugs has been linked clearly to later substance abuse (Kandel, 1980, 1982; DuPont, 1989). Thus, young people, a particularly vulnerable at-risk population, are a key target for prevention efforts.
Since its establishment in 1986, the Center for Substance Abuse Prevention (CSAP, originally the Office for Substance Abuse Prevention, or OSAP) has played a critical leadership role in the development of substance abuse prevention theory, programming, and knowledge application. An important part of CSAP’s mission within the broader context of its parent agency, the Substance Abuse and Mental Health Services Administration (SAMHSA), is to generate new knowledge about the impact and effectiveness of prevention efforts. Much of the information driving this knowledge development effort has been accumulated over the past 11 years in the form of data collection, analysis, and reports of findings from CSAP’s diverse array of demonstration grant programs.
The agency has undertaken an effort to formalize, synthesize, and extract lessons, based on hard scientific evidence, regarding the ability of intervention programs to successfully effect decreased substance use among target populations. CSAP’s substance abuse prevention programs have provided direct services to tens of thousands of children, youth, families, and communities across the country. They have been a fertile proving ground for prevention theory and technology.
Data collected by CSAP add to the growing professional literature, offering a rich body of research on risk factors for substance use and abuse among children, youth, and young adults. The major strength of this research is its predictive value: The greater number of risk factors a child experiences, the more likely it is that he or she will experience substance abuse and related problems in adolescence or young adulthood. However, risk factor research does not usually claim direct causal links between risks and later problems. Instead, behavior is viewed as the result of complex interaction of risk and protective factors in which the protective factors in an individual’s life mitigate the potential impact of risk for substance use.
In fact, many risk factors experienced by individuals in childhood are associated not just with substance abuse but with an array of health and social problems. As the research on risk factors has accumulated, an increasingly vivid picture has emerged of a complex web of interrelated risks, protective factors, and problem behaviors.
In one very straightforward theoretical framework of substance use, six life domains—individual, peer, family, school, community, and society—are used. It is important to note that these domains interact with the individual placed at the core of the model and that all stimuli are processed, interpreted, and responded to based upon the characteristics the individual brings to the situation. This provides a framework in which to understand the interactive effects of risk and protective factors. Additionally, it provides guidance about which factors should be targeted by a diverse array of prevention programs.
This framework, or the “Web of Influence” see Figure 1, has been used as the organizing principle underlying the identification of domains of influence. While programs work to effect positive change in one or more of these domains, thereby increasing resiliency and enhancing protective factors, the domains are also important in understanding outcomes. Because each prevention program has as its ultimate goal to prevent, postpone, or reduce substance use, and since substance use itself is a complex product of occurrences in the other domains, it has been extracted and maintained as a separate outcome domain.
Advances in Knowledge: The HRY DataBank
Recognizing the need for a sustained effort to organize the mass of information originating among CSAP grantees, and to present findings and other pertinent information in a form that would be both useful in assessing program effectiveness and scientifically acceptable, CSAP launched a new initiative, the High Risk Youth (HRY) DataBank, in the fall of 1994. A monograph describes the process used to organize, extract, and code information; the structure and contents of the DataBank; and findings from the best-implemented and evaluated grants in the DataBank.
The HRY DataBank is an evaluation-oriented information system with a comprehensive, unifying framework. It consists of four primary information components:
- Descriptive information (e.g., administrative characteristics including location, number, and types of sites; setting; and targeted population demographics);
- Compilations of specific CSAP demonstration program interventions (prevention strategies);
- Formal characterization of the evaluation methods used; and
- Objective ratings of both strength (direction and magnitude) and credibility of findings.
For each grant, Proposals, Final Reports, Findings Papers, and annual Evaluation Status Reports were reviewed and coded to extract descriptive information regarding the implementation, population, and administrative characteristics of the program as well as to describe the evaluation methods, including sample characteristics, measures used, attrition, and findings. In addition, each report presenting information from an evaluation study measuring change over time against a standard was subjected to expert review. The purpose of this expert review was to rate level of confidence in each finding based on the characteristics of and quality of implementation of the research design. Pairs of trained external evaluators rated each finding for magnitude and confidence that the data were meaningful. In addition, ratings of confidence, magnitude, and direction were generated across all findings in each outcome domain, resulting in ratings for both individual findings and for the overall domain.
In order to determine model programs, another set of reviews was undertaken. Here, those programs identified as providing data in which the analysts had at least moderate confidence were again subjected to review by two outside evaluation experts. In this review, the research was evaluated on the basis of quality of program intervention implementation, evaluation rigor, and the positivity and consistency of findings. The focus of the monograph is on well-implemented, rigorously evaluated, effective programs. Table 1 captures information about the eight model programs, both program characteristics and findings.
Synthesis of Effective Prevention Programs
The eight programs identified as being well implemented, producing positive effects, and conducting rigorous evaluations represent a diversity of prevention strategies and target groups, yet can be viewed as representing a comprehensive approach to prevention.
The eight programs are distributed across the full range of levels of program implementation—universal, selective, and indicated prevention (Hawkins et al., 1996; Kumpfer, 1997). Universal interventions (e.g., The Child Development Project (CDP)) target general population groups without identifying those at particularly high levels of risk. Universal interventions are those that attempt to prevent substance use by addressing the problem within an entire community. All members of the community potentially benefit from prevention efforts, rather than specific individuals or groups within a community.
Selective interventions (e.g., Across Ages (AA); Creating Lasting Connections (CLC); Dare To Be You (DTBY); Greater Alliance of Prevention Systems (GAPS); SMART Leaders (SL); Involving Parents of HRY in Prevention, Family Advocacy Network (FAN)) target those individuals who are at greater-than-average risk for substance abuse. The targeted individuals are identified on the basis of the nature and number of risk factors for substance abuse to which they may be exposed. The cumulative effect of exposure to multiple risks justifies selecting particular youth for intensive preventive efforts.
Indicated prevention efforts (e.g., Residential Student Assistance Program (RSAP)) are aimed at individuals who may already display signs of substance use or abuse. These types of programs provide intensive programming for individuals in order to prevent the onset of regular or heavy substance use. The eight programs represent each type of prevention effort and range from programs that are all-inclusive to those that target the most at-risk group of youth—institutionalized youth.
The second theoretically important concept fully demonstrated by the eight model programs focuses on developmental appropriateness. The eight programs target populations with respect to the fact that development occurs across the life span and individuals have the potential to change throughout development (Baltes, 1987). As a unit, the programs represent a lifespan approach to the prevention of substance abuse. They address developmental issues across childhood and adolescence, as well as issues in adulthood and old age. The programs targeted preschool-aged children (DTBY), elementary school students (CDP), middle school/junior high students (AA, CLC, SL, and FAN), and high school students (GAPS, RSAP, and SL). In addition, although these were not the primary target groups, the programs included parents of children and youth (AA, CLC, DTBY, and FAN) and elderly community members (AA). Effective programs have been identified across a range of ages, highlighting the ability to support effective prevention efforts throughout childhood and adolescence.
Finally, the eight models were aimed to both reduce risk factors and enhance protective factors by employing a variety of prevention strategies. The prevention strategies used by these programs addressed the needs of the target groups, both developmentally and culturally. Prevention programs are most effective when they are tailored to the specific needs of the target audience of interest (Kumpfer, 1997). Each of the theoretically driven programs aims to reduce risk factors and enhance protective factors related to substance abuse using a multifaceted prevention approach tailored to the needs of the target audience.
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Last Updated: March 4, 2002
