Reducing Toxic Stress and Promoting

Young People’s Behavioral Health: Communities That Care

J. David Hawkins, Ph.D.

Endowed Professor of Prevention

Social Development Research Group

University of Washington School of Social Work

www.sdrg.org

jdh@uw.edu

September 23, 2014

2

Research Support from:

Funders

National Institute on Drug Abuse National Cancer Institute

Center for Substance Abuse Prevention National Institute on Child Health and

National Institute of Mental Health Human Development

National Institute on Alcohol Abuse and Alcoholism

State Collaborators

Colorado DHS Alcohol & Drug Abuse Division

Illinois DHS Bureau of Substance Abuse Prevention

Kansas Dept. of Social & Rehabilitation Services

Maine DHHS Office of Substance Abuse

Oregon DHS Addictions & Mental Health Division

Utah Division of Substance Use & Mental Health

Washington Division of Behavioral Health & Recovery

4

Prevention Logic

To prevent a

problem

before it

happens, the

factors that

predict the

problem

must be

changed.

34 Years of Research Advances

Longitudinal and

epidemiological

studies have identified

predictors of many

negative

developmental

outcomes as well as

behavioral health.

6

N/A

Protective Factors (Social Development Strategy)

7

Multiple Risks = Toxic Environment Prevalence of 30 Day Alcohol Use

by Exposure to Risk and Protective Factors

Six State Student Survey of 6th-12th Graders, Public School

Students

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 to 1 2 to 3 4 to 5 6 to 7 8 to 9 10+

Number of Risk Factors

Pre

va

len

ce

0 to 1

2 to 3

4 to 5

6 to 7

8 to 9

Number of

Protective Factors

Cumulative Risk: Prevalence of Problems

by Exposure to Risk Factors

0

10

20

30

40

50

0-1 2-3 4-6 7-9 >=10

Risk factors

%

depressive

symptomatology

deliberate self harm

homelessness

early sexual activity

Bond, Thomas, Toumbourou, Patton, and Catalano, 2000

34 Years of Prevention Advances

Experimental trials have identified over 50 effective interventions for promoting behavioral health and preventing negative developmental outcomes.

See www.blueprintsprograms.com

Wide Ranging Approaches Have Been

Found To Be Efficacious

Wide Ranging Approaches Have Been

Found To Be Efficacious

Prevention Programs/PoliciesV

iole

nc

e

Dru

g U

se

HIV

ST

I

Un

inte

nd

ed

Pre

gn

an

cy

Ve

hic

le C

ras

he

s

Ob

es

ity

Me

nta

l He

alth

9. Community Based Skills Training/Motivational

Interviewing

10. Cash Transfer for School Fees/Stipend

11. Multicomponent Positive Youth Development

12. Policies (eg., MLDA, Access to Contraceptives) P

13. Community Mobilization

14. Medical Intervention

15. Law Enforcement

16. Family Planning Clinic

13

The Seattle Social Development Project-

A Test of Raising Healthy Children

Seeks to promote bonding to school and family by increasing youths’ opportunities, skills and recognition for prosocial involvement at school and home.

Target: All urban multiethnic children in experimental

classrooms starting from Grade 1 through 6 (ages 6-12)

or from Grade 5 through 6 (ages10-12).

Funded by: The National Institute on Drug Abuse, Robert Wood Johnson

Foundation, Office of Juvenile Justice and Delinquency Prevention,

Burlington Northern Foundation

14

Raising Healthy Children

• In-Service Teacher Training – Classroom management

– Interactive teaching

– Cooperative learning

• Parent Workshops – Catch ‘em Being Good

– Supporting School Success

– Guiding Good Choices

• Child Social, Cognitive and

Emotional Skills Training

Effects by End of Grade 6:

California Achievement Test Scores

*p<.05 compared with controls; N = 548 to 551.

Effects by Age 18

Compared to Controls

1 2 3 4 5 6 7 8 9 10 11 12

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Control

Full Intervention

Late Tx

Control

Full Intervention

Late Tx

By age 18 Youths in the Full Intervention had

less heavy alcohol use: less lifetime violence: less grade repetition

Grade

Age

25.0% Control vs. 15.4% Full 59.7% Control vs. 48.3% Full 22.8% Control vs. 14.0% Full

Effects By Age 21

Compared to Controls

1 2 3 4 5 6 7 8 9 10 11 12

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Control

Full Intervention

Late Tx

Control

Full Intervention

Late Tx

Grade

Age

By age 21, full intervention group had:

More high school graduates: More attending university:

Fewer selling drugs: Fewer with a criminal record:

81% Control vs. 91% Full 6% Control vs. 14% Full 13% Control vs. 4% Full 53% Control vs. 42% Full

18

Effects on Sexually Transmitted

Infection Onset through Age 30

Proportion in 3 Conditions Who Met

Criteria for GAD, social phobia, MDE, or

PTSD diagnosis at ages 24 and 27

27%

21%

18%*

26%

22%

15%*

0%

5%

10%

15%

20%

25%

30%

Pre

vale

nce

Age 24 Age 27

Control

Late

Full

20

Social Development

Research Group

Mental Health Disorders

0%

10%

20%

30%

40%

50%

21 24 27 30 33

5%

10%

15%

20%

25%

30%

21 24 27 30 33

Control

Full Interv.

Mental health

disorder a

Major depressive

episode

Analyses control for

having been born to

a teen mother.

Shaded data points:

■ p<.10

■ p<.05

a Includes major depressive episode, generalized anxiety disorder, social

phobia, and PTSD.

Effects Through Age 33

21

But…

Prevention approaches that do not work or

have not been evaluated are more widely

used than those shown to be effective.

22

The Challenge

• To increase use of tested and effective

prevention policies, programs and

practices…

while recognizing that communities are

different from one another and need to

decide locally what programs they use.

23

Snapple Fact #101

• Young people in different communities are

exposed to different levels of risk and

protection.

24

Why a Place Based Approach?

Communities Vary in Protection & Risks

A Place Based Approach

Hypothesis:

Local choice and implementation of evidence based

programs to address widespread risks in the

community will produce community wide effects on

youth health and behavior outcomes.

26

Communities That Care

Develops Capacity to

Build a coalition of diverse stakeholders

to achieve collective impact.

Assess and prioritize for action- risk,

protection, and behavioral health

outcomes.

Strengthen protection and address

priority risks with effective preventive

interventions.

Sustain high fidelity implementation of

preventive interventions to reach all

those targeted.

Measure progress and outcomes

CTC’s Five Phases

28

CTC Trainings

1. Key Leader Orientation

2. Community Board Orientation

3. Community Assessment Training

4. Community Resource Assessment Training

5. Community Planning Training

6. Community Program Implementation Training

29

CTC Logic Model

CTC Coalition

Functioning &

Capacity

Adoption of

Science-Based

Prevention

Community

Norms

Social

Development

Strategy

Community

Support for

Prevention

Community

Collaboration for

Prevention

Positive Youth

Outcomes

Decreased Risk &

Enhanced

Protection

Appropriate Selection

& Implementation of

Tested, Effective

Prevention Programs

CTC Training &

Technical

Assistance

30

Communities that Care

Process and Timeline

Assess risk,

protection and

resources

Implement and

evaluate

tested

prevention

strategies

Increase in

priority

protective

factors

Decrease in

priority risk

factors

Increase in

positive youth

development

Reduction in

problem

behaviors

Vision for a

healthy

community

Process Measurable

Outcomes

6-9 mos. 1 year 2-5 years 4-10 years

31

Community Youth Development Study:

A Test of Communities That Care

24 incorporated towns

~ Matched in pairs within state

~ Randomly assigned to CTC or control condition

5-year implementation phase

5-year sustainability phase

Longitudinal panel of students

~ N=4,407- population sample of public schools

~ Surveyed annually starting in grade 5

32

CTC Towns:

Coalition of Stakeholders

Received six CTC trainings

Collected data on local levels of risk and protection

Prioritized risk and protective factors to address

Implemented tested prevention policies and

programs from menu

na

34

Communities Targeted a Variety of

Risk Factors

CTC Community

RISK FACTORS 1 2 3 4 5 6 7 8 9 10 11 12

Laws and norms favorable to drug use x

Low commitment to school x x x x x x x x x

Academic failure x x x x x

Family conflict X x x

Poor family management x x x x

Parental attitudes favorable to problem

behavior

x

Antisocial friends X x x x x x x

Peer rewards for antisocial behavior X x

Attitudes favorable to antisocial behavior X x x

Rebelliousness X x x

Low perceived risk of drug use x x

35

Number of CTC communities

implementing effective programs

2004-2008 Program 2004-05 2005-06 2006-07 2007-08

Sch

oo

l-B

as

ed

All Stars Core 1 1 1 1

Life Skills Training (LST) 2 4* 5* 5*

Lion’s Quest SFA (LQ-SFA) 2 3 3 3

Project Alert - 1 1 1

Olweus Bullying Prevention Program - 2* 2* 2*

Towards No Drug Abuse (TNDA) - - - 2

Class Action - - - 1*

Program Development Evaluation Training 1 1 - -

Sele

cti

ve

Aft

er

sch

oo

l

Participate and Learn Skills (PALS) 1 1 1 2

Big Brothers/Big Sisters 2 2 2 1

Stay SMART 3 3 1 1

Tutoring 4 6 6 7

Valued Youth 1 1 1 -

Fam

ily

Fo

cu

se

d Strengthening Families 10-14 2 3 3 2

Guiding Good Choices 6 7* 8* 7

Parents Who Care 1 1 - -

Family Matters 1 1 2 2

Parenting Wisely - 1 1 2

Total number of programs 27 38 37 39

*Some funded locally

(Fagan et al., 2009)

36

Numbers exposed to

effective programs

Program Type 2004-05 2005-06 2006-07 2007-08

School-Based 1432 3886 5165 5705

After-school* 546 612 589 448

Family Focused 517 665 476 379

*Includes PALS, BBBS, Stay SMART, and Tutoring programs

Note: Total eligible population of 6th, 7th, and 8th-grade students in

2005-06 was 10,031.

(Fagan et al., 2009)

37

CTC Logic Model

CTC Coalition

Functioning &

Capacity

Adoption of

Science-Based

Prevention

Community

Norms

Social

Development

Strategy

Community

Support for

Prevention

Community

Collaboration for

Prevention

Positive Youth

Outcomes

Decreased Risk &

Enhanced

Protection

Appropriate Selection

& Implementation of

Tested, Effective

Prevention Programs

CTC Training &

Technical

Assistance

38

CTC Logic Model

CTC Coalition

Functioning &

Capacity

Adoption of

Science-Based

Prevention

Community

Norms

Social

Development

Strategy

Community

Support for

Prevention

Community

Collaboration for

Prevention

Positive Youth

Outcomes

Decreased Risk &

Enhanced

Protection

Appropriate Selection

& Implementation of

Tested, Effective

Prevention Programs

CTC Training &

Technical

Assistance

39

na

na

41

Effects of CTC on Incidence of

Behavior Problems

In the panel by grade 8, youth in CTC

communities were

33% less likely to start smoking cigarettes

32% less likely to start drinking

25% less likely to start engaging in

delinquent behavior

…than those from control communities.

(Hawkins et al. 2009)

42

Effects of Communities That Care on

Prevalence of Current Behaviors

In the panel, in grade 8 youth in CTC communities

were:

23% less likely to drink alcohol

currently than controls.

37% less likely to “binge” (5 or more

drinks in a row) than controls.

Committed 31% fewer different delinquent

acts in past year than controls. (Hawkins et al., 2009)

Sustained Effects One Year after

Intervention Funding Ended

• In the panel, compared to controls, 10th graders

from CTC communities had:

– Lower levels of targeted risk factors.

– Less initiation of delinquent behavior,

alcohol use, and cigarette use.

– Lower prevalence of past-month cigarette use.

– Lower prevalence of past-year delinquency

– Lower prevalence of past-year violence.

Hawkins et al., 2012, Archives of Pediatrics and Adolescent Medicine

44

Sustained Abstinence through Grade 12

Never Used Alcohol

p < .05 RR = 1.31

Hawkins et al., 2014

JAMA Pediatrics

45

Sustained Abstinence through Grade 12

Never Smoked Cigarettes

p < .05 RR = 1.13

Hawkins et al., 2014

JAMA Pediatrics.

46

Sustained Abstinence through Grade 12

Never Engaged in Delinquency

p < .05

RR = 1.18

Hawkins et al., 2014

JAMA Pediatrics.

47

Summary

• 8 years after CTC implementation and 3

years after study-provided resources

ended:

– CTC continued to prevent the initiation of

alcohol use, smoking, delinquency, and

violence through 12th grade.

48

Was that benefit worth the cost of CTC?

49

CTC Cost-Benefit Analysis:

using WSIPP Software Tool

Calculate Per Youth Cost of CTC Intervention

Calculate Per Youth Benefits

Compare Per Youth Costs and Benefits

~ Net Present Value

~ Benefit-Cost Ratio

Monte Carlo simulation methods

~ Investment Risk

~ Cash Flows

Per Youth Cost = $556 over 5 years (2011 dollars)

50

How Do Outcomes

Lead to Monetary Benefits? Major avoided costs and increased revenues

Direct Effects Indirect Effects

Outcome:

Initiation of Effect

Size

Criminal

Justice

System

Costs

Victim-

ization

Costs

Linked

Outcome Earnings

Gain

Health

Care

Costs

Property

Loss

Delinquency 0.15 High School

Graduation .39

(.09)

51

Benefit-Cost Analysis Summary: CTC Effects on Abstinence through Grade 12

Discounted

2011 dollars

1,000 Monte Carlo Simulations CTC 12th

Grade

Total

WSIPP

Adjust-

ments to

Effect Sizes *

Criminal

Justice

System

Victimi-

zation Earnings

Health

Care

Property

Loss

Benefits $897 $1,729 1,767 $83 $1 $4,477 $2,305

Participants 0 0 960 (17) 1 943 486

Taxpayers 598 0 353 133 0 1,085 562

Other 0 1,729 0 (100) 0 1,629 836

Other Indirect 299 0 454 67 0 820 421

Costs ($556) ($556)

* WSIPP halves effects when the program developer is involved in the trial – as it was in the CYDS (Hawkins involved).

52

Benefit-Cost Analysis Summary: CTC Effects on Abstinence through Grade 12

Discounted

2011 dollars

1,000 Monte Carlo Simulations CTC 12th

Grade

Total

WSIPP

Adjust-

ments to

Effect Sizes *

Criminal

Justice

System

Victimi-

zation Earnings

Health

Care

Property

Loss

Benefits $897 $1,729 1,767 $83 $1 $4,477 $2,305

Participants 0 0 960 (17) 1 944 486

Taxpayers 598 0 353 133 0 1,085 562

Other 0 1,729 0 (100) 0 1,629 836

Other Indirect 299 0 454 67 0 820 421

Costs ($556) ($556)

Net Present Value $3,920 $1,749

Benefit Cost Ratio 8.22 4.23

Investment Risk: % trials NPV > $0 100% 99%

* WSIPP halves effects when the program developer is involved in the trial – as it was in the CYDS (Hawkins involved).

53

CTC Discounted Cash Flows

Over 50 Years Discount rate: 3.5%

Years from Program Start

-$250

-$150

-$50

$50

$150

$250

1 6 11 16 21 26 31 36 41 46

Years from Program Start

50 40 30 20 10 35 25 15 5 45

54

Summary

Communities That Care is Cost-Beneficial – even

when effect sizes are reduced by 50%

Summary indicators are favorable

~ Net present value: $1,749

~ Benefit cost ratio: 4.23

~ Low risk of negative investment return

Largest share of benefits was from delinquency

prevention

Findings sustained from 8th through 12th grade

55

Cross-sectional Samples -

CYDS

• Found no significant effects of CTC in reducing

drug use or delinquency across 6th, 8th or 10th

grade from pre CTC (combined baseline 2000-

2002 to outcome 2006-2008).

• Longitudinal analyses (grade 6 baseline to grade

10 four years later), found only one significant

effect – smokeless tobacco use.

(Rhew et al., under review)

Why different findings?

56

• Limited power due to small number of communities?

• Repeated cross-sectional studies include a different

population of students in the baseline sample compared to the

follow-up sample. Inability to link data from individuals over

time could reduce power to detect intervention effects.

• The student population at follow-up included students who

moved to the community sometime after baseline. These

students may have had limited exposure to the CTC system

attenuating observed effects of CTC.

CTC in Pennsylvania

• Adopted as a statewide initiative in 1994

• 16 cycles of CTC training delivered.

• About 65 currently functioning CTC communities

• System of assessment & dedicated technical assistance to improve coalition functioning

• Opportunity to study CTC in a long-term large-scale implementation under real-world conditions-developer not involved

Pennsylvania’s CTC coalitions 2014

Cross-Sectional Samples Pennsylvania Data

• Cross-sectional quasi-experimental study of

98,000 students in 147 communities

• Used propensity score matching to minimize potential

selection bias

• Found youth in CTC communities reported lower rates of

risk factors, substance use, and delinquency than youth

in similar non-CTC communities (7x as many as by

chance)

• Communities using EBPs showed better outcomes on

twice as many R/P factors and behaviors (14x as many

as by chance) (Feinberg et al., 2007)

5 year Longitudinal Study of PA Youth

-20

-10

0

10

20

30

40

-10.8

33.2

-10.8

16.4

Delinquency Academic Performance

Negative Peer Influence School Engagement

% Change of CTC/EBP Youth Over

Comparison Group

419 age-grade cohorts over a 5-year period:

youth in CTC communities using EBPs had significantly lower rates of delinquency,

greater resistance to negative peer influence,

stronger school engagement and better academic achievement

Feinberg, M.E., Greenberg, M.T., Osgood, W.O., Sartorius, J., Bontempo, D.E. (2010). Can Community Coalitions Have a

Population Level Impact on Adolescent Behavior Problems? CTC in Pennsylvania, Prevention Science.

61

How does CTC produce better

outcomes?

• Communities That Care

increases adoption of

science based

prevention by key

community leaders.

• Key leader adoption of a

science based approach

to prevention is the

mechanism by which CTC

leads to significant

reductions in youth

crime and drug use. (Brown et al. 2013)

62

Adoption of a Science-Based

Approach to Prevention

No

Awareness

Awareness of

prevention

science

terminology &

concepts

Use of risk

and

protection-

focused

prevention

approach as

planning

strategy

Use of

epidemiological

data on risk and

protection in

prevention

planning

Selection of

tested and

effective

interventions

to address

prioritized risk

and

protective

factors

Use of tested

and effective

interventions,

collection of

program

process and

outcome

data, and

adjustment of

interventions

based on

data

Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

63

Why do communities adopt

science based prevention?

CTC training is key to ensuring adoption

of science based prevention and to

effective functioning of coalition.

(Gloppin et al. in press)

64

Challenge

• CTC training has been delivered live through 6

visits to each CTC community by a certified trainer

over several months.

• This limits flexibility in scheduling workshops and

makes providing the CTC workshops, refresher

workshops, and training of new leaders and

coalition members costly.

• It makes spreading CTC to a large number of

communities difficult.

65

Solution

The eCTC Training and Implementation Support

System.

Component 1

Web streamed workshop series:

• Locally facilitated

• Content provided via brief embedded videos

• Activities ensure knowledge and skill acquisition and

application

66

Benefit

Web-streamed locally

facilitated workshops

make spreading CTC

to many new

communities feasible

without requiring

large numbers of

travelling certified

CTC trainers.

67

www.communitiesthatcare.net

J. David Hawkins, Ph.D. Endowed Professor of Prevention

www.sdrg.org jdh@uw.edu

• End of Powerpoint -extra slides below

here.

68

Adoption of

Science-based

Prevention

(2004)

Student Problem

Behavior

(2007)

CTC Training and

Technical Assistance

(2003)

Adoption of Science-

Based Prevention is Key

b = -.561*, R2 = .47

b = 1.11** , R2 = .42 b = -.05*, R2 = .39

Indirect Effect: b = -.06*,

96% variance explained

* p < .05

** p < .01

CTC Implementation Worldwide

• United

States

• Canada

• Australia

• Netherlands

• Germany

• United

Kingdom

• Colombia

• Sweden

The CTC Survey is being used or adapted in Brazil,

Chile, India, and Croatia.

72

Additional Assumptions

Participant age: 18 (12th Grade)

Benefits stream ends: Crime to age 59

Earnings to 65

Health care costs to 100

Property losses to 100

Deadweight cost of taxation: Included in model at 50%

Discount rate: 3.5% (range: 3.3 – 4.0%)

Results expressed in: Discounted 2011 dollars

To what extent does participation in CTC training

workshops increase use of science-based prevention

reported by community leaders?

73

Reported stages of adoption of science-based

prevention in CTC Communities by trained

leaders v. leaders not trained

74

62%

17%

58%

21%

44%

13%

Analysis

• Multi-level models to account for nested data:

– 4407 Students

– 24 Communities

– 12 Matched Pairs

• Adjustment for student and community characteristics

– Students: Age, race, ethnicity, parental education, religious

attendance, rebelliousness.

– Community: Student population, % of students receiving

free/reduced price school lunch.

• Missing data approach:

– 40 imputed data sets

– Results averaged using Rubin’s rules