Executive Summary
The majority of adolescents will engage in substance use (e.g., nicotine/tobacco, alcohol, cannabis) between the ages of 12-21. While most will not develop a substance use disorder (SUD), substance use of any kind during adolescence is concerning given the detrimental impact of substances on the developing brain. Moreover, for a subset of youth, substance use will become more frequent and problematic, leading to negative effects on their development, health, and well-being. The effects of substance use/misuse accumulate over time and significantly contribute to costly social, physical, mental, and public health problems. The development of SUDs, including opioid use disorders (OUDs) is often preceded by a variety of other problems including academic failure, antisocial behavior, anxiety, depression, and traumatic stress. These problems often arise due to environments within the home, school, or neighborhood that are unsafe, under-resourced, or otherwise harmful to social, academic, and behavioral development.
The three most important environments affecting young people’s development are families, schools, and neighborhoods, all of which offer opportunities for intervention. Effective programs shown to prevent teens from developing SUDs work within these environments to strengthen cognitive control over emotional and impulsive reactions, foster healthy relationships, teach effective ways of managing stress, reduce traumatic experiences, and provide nurturing settings for healthy development. One of the most effective prevention approaches involve the implementation of early intervention strategies that prevent problems from occurring or tackle them head-on when they do appear before problems worsen. It works by identifying and providing early supports and programs to children and adolescents who are at risk of a variety of poor outcomes that tend to be related to one another; e.g., substance misuse, delinquency, school drop-out, depression, and other mental and behavioral problems. Implementing these programs well through supportive infrastructure and policies can yield significantly more benefits than costs. Taxpayers benefit when investments are made in these successful research-based programs rather than waiting and reacting to already serious substance use problems that are much more difficult and costly to address. Prevention is increasingly recognized as an essential element for tackling pandemics, social and racial injustices, health disparities, and other adversities. As states are about to receive heavy infusions of money from the pharmaceutical settlements, they have the unique and urgent opportunity to promote the scaling up and scaling out of effective prevention.
Recommendations
1. Select and implement family and school programs shown to reduce behavioral problems and substance use.
The best available research evidence enables researchers, practitioners, and policymakers to determine whether or not a prevention program, practice, or policy is actually achieving the outcomes it aims to and in the way it intends.
2. Identify at-risk youth.
Use evidence-based screening tools to identify youth with a high probability for risky behaviors and train staff and practitioners in Youth Mental Health First Aid to learn strategies to help identify, understand, and respond to signs and symptoms of mental health and substance use challenges. [See below.]
3. Intervene early.
Early intervention can take different forms, such as home visiting programs, support for disadvantaged parents in the postnatal period, school-based programs shown to improve children’s social and emotional skills, brief motivational interventions to promote behavior change, and mentoring young people who are vulnerable to involvement in crime.
4. Focus on promoting evidence-based investments supported by technical assistance and a built-in plan for continuous quality improvement.
A shared measurement system—where multiple organizations use a common set of measures to evaluate performance and track progress toward goals—can account for how dollars are spent and can clearly attach to the outcomes of programs supported by opioid settlement funds.
5. Embed strong community-level support.
A continuum of resources, delivered by local organizations providing community-based prevention, treatment, aftercare/recovery, and ongoing maintenance, is vital for a community-driven response to local needs.
6. Use existing infrastructures when possible.
The Center for Medicare and Medicaid Services developedEPSDT (Early and Periodic Screening, Diagnostic and Treatment) in 2014 to guide the provision of an array of prevention, diagnostic and treatment services for children who are enrolled in the Medicaid program. Medicaid could oversee and coordinate statewide implementation of prevention policies by tying into federally supported prevention initiatives such as EPSDT and Bright Futures.
7. Engage an informed and capable workforce.
To achieve long lasting improvements, professionals who work with at-risk youth and families in communities with a high prevalence of risk conditions should be trained and equipped with the tools to carry out this work and certified that they meet standards demonstrating their knowledge, skills, and competencies to effectively deliver evidence-based prevention interventions. This workforce spans educational, justice, public health, primary care, child welfare, and other sectors/systems, each containing its own infrastructure, so it is important that all those who will deliver prevention programming have the same training and credentialling.
8. Enact policy change.
Changes to federal, state, and local policies affect the full range of institutions and structures in neighborhoods, communities, and society, including families, schools, churches, health care systems, community organizations, businesses, and corporations. The resulting characteristics and actions of those institutions and structures in turn affect the physical, economic, and social environments experienced by children and their families in their communities. Thus, policy can influence the distribution of wealth (e.g., EITC), employment (e.g., training programs), and the health care (e.g., Bright Futures), education (e.g., social-emotional learning), child welfare (e.g., child support), and juvenile justice systems (e.g., diversion) and will, thus, have more far reaching and sustainable impacts than any specific programs. See the National Academy of Sciences, Engineering and Medicine Report, 2019.
Strategies
Evidence-Based School and Family Programs to Reduce Problem Behaviors & Substance Use
Each of the following programs are considered “evidence-based” and can be found on the Blueprints for Healthy Youth Development website along with additional background material, implementation advice, and resources. These programs are developmentally appropriate and have been shown to either prevent the initiation of substance use or escalation of use. The National Prevention Science Coalition to Improve Lives (NPSC) also offers subject matter experts and additional guidance around conducting needs assessments, selecting programs appropriate for the community, implementing and evaluating prevention programs, and leveraging existing infrastructure to support their delivery.
Good Behavior Game (GBG) and the PAX GBG (ages 6-10 – first or second grades) |
These universal school-based primary prevention programs include a set of strategies to help students learn and practice applying important self-management skills while collaborating to make their classroom a peaceful and productive learning environment. The Good Behavior Game (GBG) and the PAX GBG are not classroom management programs, but they make managing classrooms much easier. The programs contain the combined science from the youth violence prevention program called Peace Builders, the GBG, and other studies. Outcomes include improved mental and behavioral health outcomes from childhood into adulthood. GBG has been shown to prevent substance use and is rated as a “Promising Program” in Blueprints. For more information, please visit: PAXGBG website and AIR.org |
Triple P (Parents of children from birth to age 12 years, and Teen Triple P for parents of teens aged 12-16) |
Triple P is a positive parenting program that affects multiple outcomes and reduces risk for SUDs. It is provided by practitioners and organizations in the community, clinicians in treatment facilities, and other settings. Triple P is a broadly focused parenting support intervention offering one-to one or group training for parents of children up to 16 years. After thorough family assessment, parents set their own goals, learn ways to encourage positive behavior for children and teens, and teach their teens new skills such as problem solving, conflict resolution, and self-regulation. Over 10 sessions, parents identify the influences on children and teens’ behavior and set their own goals for change. Parents also learn ways to use appropriate consequences for problem behavior (e.g., breaking family rules, taking inappropriate risks, emotional outbursts). Triple P has been shown to prevent substance use and is rated as a “Promising Program” in Blueprints. For more information, please visit the Triple P website. |
Project TND (Towards No Drug Abuse) Late Adolescence (ages 15-18)- High School |
An interactive classroom-based substance abuse prevention program that focuses on three factors that predict tobacco, alcohol, and other drug use, violence-related behaviors, and other problem behaviors among youth, including: Motivation factors (i.e., students’ attitudes, beliefs, expectations, and desires regarding drug use); Skills (effective communication, social self-control, and coping skills); and Decision-making (i.e., how to make decisions that lead to health-promoting behaviors). Project TND is rated as a “Model Program” in Blueprints. For more information, please visit the Project TND website. |
Strengthening Families Program (SFP) (SFP 10-14) and its adapted version Strengthening African American Families (SAAF) |
SFP is an evidence-based family skills training program for high-risk and general population families, and can be useful for parents with SUD and their children. It includes 14 sessions of teaching evidence-based parenting skills, children’s social skills, and family life skills. Parents and children participate in SFP both separately and together. Group Leader Manuals contain a complete lesson for every session. Parents’ and children’s handouts are also provided for every session. SFP has been shown to prevent substance use and is rated as a “Promising Program” in Blueprints. The adapted version SAAF is also rated as a “Promising Program”. For more information, visit the SFP website. |
Raising Healthy Children (RHC) (grades 1-12) |
Raising Healthy Children (RHC) is a comprehensive, school-based preventive intervention that concentrates on promoting positive youth development by using a social developmental approach to target risk and protective factors. The school and family environment are incorporated into the individual programming, which targets the child. The program covers children from kindergarten through high school with developmentally and age-appropriate material at different stages. The main goals of RHC are to increase school commitment, academic performance, and social competency and to reduce antisocial behavior. RHC is rated as a "Promising Program"in Blueprints. For more information, please visit the RHC website. |
Life Skills Training (LST) (elementary, middle, high school, and parent modules) |
LST is a school-based program shown to reduce substance use and violence through cognitive-behavioral skills that enhance self-esteem, decision-making, problem solving, and critical thinking. The LST Middle School program is designed to be taught in sequence over three years. The first year of the program consists of 15 class sessions (plus 3 optional violence prevention sessions), the second year 10 sessions (plus 2 optional violence prevention sessions), and the third year 5 sessions (plus 4 optional violence prevention sessions). LST has consistently and repeatedly been shown to prevent substance use and is rated as a “Model Plus Program” in Blueprints. For more information, please visit the LST website. |
Multisystemic Therapy (MST) (ages 12-17 years) |
MST is a family-driven treatment that is culturally responsive and centered in homes and communities. Therapists work in the home, school and community and are on call 24/7 to provide caregivers with the tools they need to transform the lives of troubled youth. When partnered with law enforcement and the juvenile justice system, it plays a unique bridge-building role in achieving shared outcomes for minority youth, families, schools, and communities at large. Research demonstrates that MST reduces criminal activity, substance use, and other undesirable behaviors. At the close of treatment, 87% of youth have no arrests. MST has consistently and repeatedly been shown to prevent substance use and is rated as a “Model Plus Program” in Blueprints. For more information, please visit the MST website. |
Identifying Youth In Need of Services
The following are evidence-based approaches that can be used to identify youth who need assistance to improve their outcomes.
1. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based framework used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. SBIRT is most frequently employed during well-child check-ups and school health and psychological services to reinforce healthy choices and support early identification, intervention, and referral to treatment. A highly adaptable framework, SBIRT can be implemented within a number of systems that encounter at-risk children, adolescents, and families (e.g., education, pediatric health care, criminal justice, child welfare). There are several well-validated tools that can aid in the identification of risk.
a. The Youth Risk Index© (YRI) can identify young people who have a high propensity for risky behaviors years before those behaviors occur or become harmful. Research on the YRI has found that it can accurately predict multiple early risky behaviors for adolescents ages 9 to 13 and that it predicts development of SUD later in adolescence with a high degree of certainty. The YRI is acceptable to youth, parents, and service providers.
b. The CRAFFT 2.1 screening tool is an efficient way to identify youth substance use, substance-related riding/driving risk, and substance use disorder in ages 12-21. This tool utilizes a pre-screen to assess frequency of past year alcohol, marijuana, nicotine/tobacco, and other drug use along with history of riding or driving in a car driven by someone under the influence. Positive endorsements on the pre-screen trigger additional questions to assess substance-related problems suggestive of substance use disorder.
c. The Screening to Brief Intervention (S2BI) is a quick frequency-based screen used to identify past year adolescent tobacco, alcohol, and marijuana use. Positive endorsements lead to additional screening of prescription drug, illegal drug, inhalant, and synthetic drug use.
2. Youth Mental Health First Aid. This program teaches adults who work with youth, including teachers, school staff, coachers, parents, camp counselors, and youth group leaders, how to identify, understand, and respond to signs and symptoms of mental health and substance use challenges among children and adolescents and provides a basis for referral to services. Subjects covered include the common signs and symptoms of mental health and substance use challenges in youth, how to interact with a child or adolescent in crisis, and how to connect the youth with help. The training includes expanded content on trauma, substance use, self-care and the impact of social media and bullying, and use of the Mental Health First Aid Action Plan (ALGEE): Assess for risk of suicide or harm; Listen nonjudgmentally; Give reassurance and information; Encourage appropriate professional help; and Encourage self-help and other support strategies.
Building a Backbone Infrastructure to Achieve Successful Outcomes
A strong community-based infrastructure is needed to support delivery of preventive interventions made possible via the pharmaceutical settlement monies. We recommend a 5-phase process that results in a Substance Prevention Service Delivery System (see figure) for the effective and cost-efficient implementation of interventions known to reduce SUD/OUD. The phases include:
Families, community members and professionals across sectors convene to decide on goals, programs, desired outcomes, and actions for successful implementation efforts. Sectors may include health care, law enforcement, schools, and the judiciary among others.
Their ideas and plans are shared with the public and local officials for additional input and support for the community-based delivery system that best reflects the needs and preferences of the community.
Service providers such as medical offices, mental health and family support services, and school counselors are trained in how to best provide these prevention programs and services.
A tracking and assessment system for screening, early intervention, referrals, and monitoring is set up for relevant agencies and other settings (such as family practice or pediatric offices, schools, and family courts) to link teens and families with evidence-based practices.
A document is produced that provides a set of instructions to guide the establishment, monitoring, evaluation, and improvement of the prevention services delivery system to support parents and their children.
Resources
For further information, resources, trainings, and other guidance, please access the following websites:
Prevention Technology Transfer Center Network (PTTC): https://pttcnetwork.org/
Evidence-based Prevention and Intervention Support (EPIS) Center: https://epis.psu.edu/
Applied Prevention Science International: https://www.apsintl.org/
A Division for Advancing Prevention and Treatment (ADAPT): https://www.hidta.org/adapt/
Coalition for the Promotion of Behavioral Health (CPBH): https://www.coalitionforbehavioralhealth.org/
Community Anti-Drug Coalitions of America (CADCA): https://www.cadca.org
Authors
Dr. Diana Fishbein (dfishbein@unc.edu)
Senior Scientist, FPG Child Development Institute,University of North Carolina-Chapel Hill, Part-Time Faculty at Penn State University, and Founder/Co-Director of the National Prevention Science Coalition to Improve Lives
Dr. Zili Sloboda (zili.sloboda@apsintl.org)
President, Applied Prevention Science International, Inc.
Dr. Melissa Clepper-Faith (mclepperfaith@unc.edu)
Translational Research Program and Policy Coordinator,FPG Child Development Institute, University of NorthCarolina-Chapel Hill
A Division for Advancing Prevention & Treatment (ADAPT)
Point of contact: Dr. Lora Peppard (lpeppard@wb.hidta.org)
Director of ADAPT, Washington/Baltimore HIDTA
And the national Consortium to Advance Prevention Solutions to the Opioid Crisis (CAPSOC)
