Preventing Youth Problems (Issues in Childrens and Families Lives)

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Prevention and early intervention is the process of identifying and responding early to reduce risks or ameliorate the effect of less-than-optimal social and physical environments. Prevention services are designed to promote the safety, welfare and wellbeing of children, young people and their families and prevent the development or emergence of problems and issues. They may be targeted to specific community groups who have a history or greater chance of developing certain problems or issues due to the existence of known risk factors or vulnerabilities. Alternatively, it refers to intervening as soon as a problem is apparent.

One of the goals of early intervention is to prevent the escalation of serious issues that may require a more intensive response involving the statutory child protection or justice systems. Prevention programs and early intervention programs together operate across the full continuum of service supports.

PREVENTION AIMED AT FAMILY FUNCTIONING

While services across the spectrum vary considerably in character and intensity, the following are some common principles which link all prevention and early intervention services. Voluntary participation is usually voluntary. This promotes family empowerment, including participation in making decisions about their lives while they are involved in a program. This approach recognises that each person already has skills and expertise in relation to their lives, and their families.

A strengths-based approach aims to enhance motivation, participation and realisation of identified goals and positive outcomes. Child centred - a child-centred approach means that the focus of intervention is on the child or young person and on realising positive outcomes for that child or young person. Family focused - while services are child-centred they are also family-focused. Additional parenting interventions are highlighted in the next section.

Prevention and early intervention strategies

Interventions that combine training in parenting skills with school-based interventions are described later in the chapter. Early adolescence is a developmental period during which the prevalence of substance use, delinquency, and depression begins to rise.

There is also evidence of an increase in the rates of teasing and harassment in middle school. Significant physical changes occur with the onset of puberty, along with social changes, including the transition from elementary school to middle school or junior high school, increased concern about peer acceptance Steinberg, , and increased demand for autonomy Eccles, Midgley, et al.

Major environmental risk factors that are especially important in early adolescence include family poverty and family conflict, as well as inadequate parental monitoring and deviant peer group formation. A key behavioral risk factor is aggressive social behavior, which contributes to social rejection and deviant peer group formation Patterson, DeBaryshe, and Ramsey, In addition, young people who use cigarettes and alcohol are more likely to use other drugs Kandel, Johnson, et al. More generally, psychological and behavioral problems tend to be interrelated Biglan, Brennan, et al.

Boxes and describe two parenting interventions using the parenting skills techniques discussed above that have been developed and evaluated in multiple randomized controlled trials. They are adapted to address the unique issues, such as potential substance use and parental monitoring, that arise as young people enter early adolescence. The Strengthening Families Program SFP and adaptations of it see Box is a universal intervention that has demonstrated positive results on a range of outcomes. The Adolescent Transitions Program see Box has evolved over a series of trials to an intervention with universal, selective, and indicated components designed for delivery in schools.

It has demonstrated long-term effects on substance use and delinquency among both white and minority youth. Strengthening Families Program and Adaptations: The Adolescent Transitions Program ATP is a multilevel, adaptive parenting intervention designed to reach parents through middle schools Dishion and Kavanagh, ; Dishion, more Without these conversations, adolescents overestimate the level of parental approval of their sexual behaviors, and mothers underestimate the amount of sexual activity of their adolescents Jaccard, Dittus, and Gordon, Such communication appears to depend on warm and supportive parent—child relationships Donenberg, Bryant, et al.

Conversely, family conflict and negative affect are associated with behavioral problems Szapocznik and Kurtines, , such as earlier sexual debut Paikoff, and generally risky sexual behavior Biglan, Metzler, et al. Parental monitoring and an authoritative parenting style are consistently associated with less risky sexual behavior, fewer sexual partners, less pregnancy, and increased condom use among youth in the family see Biglan, Metzler, et al. Several interventions target HIV risk reduction. Like other parent-oriented interventions, they focus on improving parent—child communication and supportive parental behaviors and increasing parental monitoring and limit setting.

Although no meta-analyses have been conducted for these programs, a growing body of evidence is available for such interventions Krauss, Goldsamt, and Bula, ; Wills, Gibbons, et al. Some interventions have targeted and successfully reduced both early sexual intercourse and substance use McKay, Bannon, et al. Two HIV prevention interventions have been tested in multiple trials.

Trials of the Chicago HIV Prevention and Adolescent Mental Health project, a family-based, universal HIV prevention program targeting youth in fourth and fifth grades, showed a number of benefits, such as enhanced family decision making, improved caregiver monitoring, and fewer disruptive difficulties with children McKay, Chasse, et al. Familias Unidas, which targets Hispanic immigrant parents and their children, was found to increase parental involvement and improve communication and support, and resulted in fewer adolescent behavior problems Pantin, Coatsworth, et al.

Adolescence is a period of more independent decision making and risk taking, when the role of parents remains significant but is matched by the influence of peers. Preventive interventions during this stage of development are typically delivered directly to adolescents through schools, and these are discussed later in this chapter. Some treatment interventions show positive effects for families with adolescents displaying considerable antisocial behavior or substance use.

For example, multisystemic therapy e. These benefits include reduced escalation of antisocial behavior and substance use. These interventions are based on the same principles of effective parenting as the interventions discussed above and may be adaptable for prevention. Parental monitoring can also reduce adolescent alcohol use National Research Council and Institute of Medicine, A growing body of research points to the period between age 21, generally viewed as the end of adolescence, and age 25 as a notable developmental phase in the transition to adulthood Furstenberg, Kennedy, et al.

These young adults face unique challenges involving the transition to and from college or full-time jobs including the military , formation of marriage and families, and assumption of increasingly more responsible roles. At the same time, many of these young adults are living at or returning home for long periods of time, increasing the potential role of parents and other family members.

Yet little research has been done on family-oriented interventions during this developmental phase. Some environments in which young people live introduce new factors that may affect their mental, emotional, and behavioral health, such as the presence of binge drinking and pressures to drink on college campuses. For young adults who enter the military, exposure to combat and serious trauma can have severe mental, emotional, and behavioral consequences. Some of the service branches and other groups are undertaking efforts to deal with such stressors Saltzman, Babayon, et al. Many of the preventive interventions described in this report are conceptually relevant to members of the armed forces and their families.

However, consideration of how these interventions could be used in the military context, given differences in service systems and many other aspects of military and civilian life, is beyond the scope of this report. Such family situations as mental illness, divorce, death, and abuse can affect family functioning and contribute to MEB disorders. Selective interventions to help families deal with these adversities and prevent negative outcomes among children have been developed and tested. Interventions designed for families dealing with parental depression are discussed in Chapter 7.

Compared with adolescents in two-parent homes, those with divorced parents exhibit higher levels of mental, emotional, and behavioral problems and lower levels of success in developmental tasks in childhood and adolescence; this increased risk persists into adulthood Amato and Soboleski, ; Amato and Keith, a , b. Parental death is also associated with multiple problems in childhood and adulthood, including more symptoms of depression and anxiety and higher rates of depression and post-traumatic stress disorder Cerel, Fristad, et al.

Preventive Interventions for Divorcing Families. A number of prevention programs focus on improving outcomes for children who experience parental divorce Braver, Griffin, and Cookston, ; Emery, Sbarra, and Grover, ; Grych and Fincham, ; Haine, Sandler, et al. Many of these programs work with parents during and after the divorce or target changing the divorce process. At least two programs with positive results work with the mother during and after the divorce to deal with the stressors involved: A randomized controlled trial of the PTC program demonstrated reductions in coercive parenting, antisocial behavior, and internalizing behavior at month follow-up and reductions in delinquency at month follow-up DeGarmo, Patterson, and Forgatch, ; Martinez and Forgatch, ; Patterson, DeGarmo, and Forgatch, Two trials of the New Beginnings Program demonstrated positive results, with some benefits sustained at six-year follow-up see Box The New Beginnings Program: One randomized controlled trial of a program for noncustodial fathers, Dads for Life, has shown positive effects.

The program teaches skills to improve father—child relationships and reduce postdivorce interparental conflict. Two studies evaluating the effects of programs targeted at changes in the divorce process have shown positive effects in improving the postdivorce relationship between the parents Emery, Sbarra, and Grover, ; Pruett, Insabella, and Gustafson, Finally, programs directed at children through schools have had benefits in reducing internalizing and externalizing problems Pedro-Carroll, Sutton, and Wyman, ; Stolberg and Mahler, A meta-analysis of 13 evaluations of interventions Currier, Holland, and Neimeyer, to address the needs of parentally bereaved children failed to find significant effects.

The studies had numerous methodological weaknesses, however, including small sample sizes and a lack of follow-up assessments. Two programs that produced mental health outcomes each were tested in a single randomized controlled trial. The Family Bereavement Program was tested in a randomized controlled trial involving families. Compared with a literature-only control, results for parents in the program included improved positive parenting, mental health, and coping and a reduction in stressful life events; for children, inhibition of expression of feelings was reduced. At month follow-up, the program participants continued to show improvement, and children who had greater internalizing problems when they began the program showed significant decreases.

In addition, girls in the intervention condition showed a reduction in externalizing and internalizing problems compared with girls in the control condition Schmiege, Khoo, et al. The program helped parents discuss their disease with their children, prepare them for the transition to a new caretaker, and facilitate their coping. Programs that target child maltreatment have the potential to prevent multiple MEB disorders and promote healthy development across several domains of functioning.

One meta-analysis reviewed 40 evaluations of selective interventions providing early support prenatal to age 3 to families at high risk for child maltreatment Geeraert, Noortgate, et al. The authors found a significant decrease in abusive and neglectful acts and a significant risk reduction in such factors as child, parent, and family communication and functioning.

A meta-analysis by MacLeod and Nelson reviewed multiple programs designed to promote family wellness and prevent maltreatment of children up to age Examples included home visiting; community-based, multicomponent interventions providing services such as family support, preschool education or child care, and community development ; media interventions; and intensive family preservation services in-home support programs for families in which maltreatment had already occurred. The study concluded that most interventions designed to promote family wellness and prevent child maltreatment are successful.

Effect sizes were largest for measures of family wellness and smaller for verified or proxy measures of child maltreatment. Differences were also reported between reactive interventions in response to an incident of maltreatment , which had larger effect sizes at postassessment than at follow-up, and proactive interventions, which had larger effect sizes at follow-up than at postassessment. These differences could be attributable to variations in the risks in the populations served or in the ages of the children at the time of the intervention.

Recent research at the Oregon Social Learning Center has shown that significantly improved outcomes can be achieved through substantial training, support, and backup of parents, coupled with direct training of young people placed in foster care.

Early Intervention Foster Care EIFC is built on research that defined a set of critical parenting skills and methods for teaching them to parents and other caregivers e. The program involves a team approach to training and supporting foster parents through daily telephone contacts, weekly support group meetings for foster parents, and a hour hotline. Children also participate in weekly therapeutic play group sessions.

In a randomized controlled trial, Fisher, Burraston, and Pears found that children in the EIFC condition who had experienced failed attempts at permanent foster home placement were more likely to have a successful placement than similar children in regular foster care. One reason may be that EIFC children had significantly greater psychological attachment to their foster parents than those in regular foster care. The impact of EIFC was also shown by measures of diurnal variation in cortisol level, which is lowered when young children experience maternal deprivation, including foster care placement Fisher, Gunnar, et al.

Compared with children in regular foster care, those who received the EIFC intervention had increased diurnal variation in cortisol over the course of the intervention that became similar to the pattern for children who had not been maltreated Fisher, Stoolmiller, et al. Price, Chamberlain, and colleagues randomized foster families to receive a version of a foster family care program or usual care. The study included a multiethnic and racially diverse sample of children between the ages of 5 and Children who received the foster family care program were significantly more likely to be returned to their biological parents or other relatives and had reduced behavior problems.

The intervention reduced the likelihood of a failed placement among those with many prior placements, primarily because of improvements in parenting practices Chamberlain, Price, et al. A quasi-experimental trial of another enhanced foster care program, the Casey Family Program, showed positive effects Kessler, Heeringa, et al. Case workers in the program had higher educations and salaries, lower caseloads, and access to a wider range of ancillary services e. Casey foster parents were provided with more financial resources and had access to more case manager assistance.

Finally, youth in the Casey program were offered post-secondary job training or a college scholarship—a major difference compared with the public programs, which did not provide services after age Adult alumni of the Casey Family Program had significantly lower month prevalence of mental disorders than public program alumni, including major depression, anxiety disorders, and substance use disorders.

Family poverty and the economic strains associated with such events as job loss frequently undermine family functioning. They are associated with multiple negative behavioral outcomes among children in these families, increase parental depression and spousal and parent—child conflict, and undermine effective parenting Knitzer, Research on interventions related to these factors has produced three notable findings.

First, economic risk factors can be modified by government policies, and some experimental studies have demonstrated that such modifications lead to a reduction in emotional and behavioral problems in children Huston, Duncan, et al. Despite considerable evidence of the impact of poverty on child and family well-being, experimental research that explores child outcomes due to reducing poverty remains limited.

Morris, Duncan, and Clark- Kauffman analyzed two approaches with the potential to affect family well-being based on seven randomized controlled trials. Four interventions involved income supplementation that provided incentives for mothers to go to work, increasing family income while also protecting government-provided benefits if the jobs were low-paying. Three other interventions sought to motivate mothers to move from welfare to work through mandates and penalties.

The former interventions significantly increased income, while the latter did not. Small but significant benefits of the programs occurred among younger children, but small and significant detriments were reported for children who were transitioning into early adolescence. No existing trial has specifically assessed the impact of poverty reduction programs on MEB disorders among young people. However, a study by Costello, Compton, and colleagues used a natural experimental situation to provide evidence of the benefit of increasing family income in reducing these disorders.

Four years into a longitudinal study of a representative sample of 1, children ages 9—13, of whom were American Indian, a casino was opened on the Indian reservation. Income from the casino significantly reduced the percentage of American Indian families in poverty, but did not affect the poverty rate among non-Indian families.

Across the eight years of the study, small but significant correlations were seen between family income and the occurrence of psychiatric diagnosis and the number of psychological symptoms in both Indian and non-Indian children. Behavioral symptoms increased significantly among children in families that remained poor as the children moved into adolescence, but declined significantly over the same period for the Indian children who were lifted out of poverty.

Similarly, there was a significant decline in the rates of internalizing symptoms for those lifted out of poverty but not in persistently poor Indian children. Although many fewer non-Indian families moved out of poverty, some did. The pattern of changes in total psychological symptoms was the same as in the Indian children.

This study has the key features of a multiple-baseline design Biglan, Ary, et al.

Although the increases in income were not assigned randomly to both Indian and non-Indian participants, it is difficult to imagine what other variable might have confounded the change in economic fortunes that occurred for the Indian children. In it lifted 4. The impact of these policies and programs on family economic well-being, family functioning, and mental, emotional, and behavioral outcomes could be evaluated in randomized controlled trials.

Developing studies to test these hypotheses empirically should be a public health priority. Thus, it is natural that a considerable number of preventive interventions have been developed for delivery in schools, including preschool settings. Most of these interventions have focused on preventing behavioral problems and externalizing disorders or promoting positive child behavior in school, although some positive results have been demonstrated on internalizing disorders, such as depression.

Other programs have focused on school structural factors, such as the reward structure for prosocial behavior or school—family relations. Preventive interventions begun early in life may have comparatively stronger effects because of the malleability of several developmentally central risk factors, such as family relationships, peer interactions, cognitive development, and emotional regulation. Early Head Start, launched in , is a federally funded extension of the Head Start Program see below targeting low-income pregnant women and families with infants and toddlers. A randomized controlled study Love, Kisker, et al.

They had significantly larger vocabularies, significantly lower levels of aggressive behavior, higher levels of sustained attention, greater engagement with parents, and less negativity toward parents. Program impact was generally larger among families that enrolled during pregnancy, African American families, and those with a moderate number of risk factors.

Families with four or five of the following risk factors did not benefit: Two years after program completion, some of the program benefits had dissipated positive effects on aggressive behavior or negativity during play were not sustained , and additional benefits emerged including enrollment in formal education programs and positive interactions in the home.

Preschool education has been shown to have positive effects on the language skills, literacy, and general cognitive ability of young children in several evaluations of high-quality programs Yoshikawa, Schindler, and Caronongen, Two meta-analyses report overall positive outcomes of preschool programs.

In a review of 13 evaluations of state-funded preschool programs for children ages 3—5, Gilliam and Zigler report improved developmental competence. Although significant impact was limited to kindergarten and first grade, some effects, including increased later school attendance and decreased grade retention, were sustained for several years. Only four of the evaluations assessed behavior problems; one of these showed a significant long-term effect through fourth grade. Effects on social-emotional functioning were sustained even after children had finished high school.

Pre-school children continued to do better in elementary school, but the differences were not significant. Programs with more child and family contact also had significantly greater impact on both cognitive functioning during preschool years and family functioning when children were in elementary school.

Temple and Reynolds review the benefits of three comprehensive early education programs: All three programs sought to improve educational attainment through a focus on cognitive and language skills and use of small class sizes and well-qualified teachers. All three programs conducted follow-up assessments into adulthood, which included at least 87 percent of study participants. Important academic outcomes were found, including less use of special education services, less grade retention for two of the programs , higher grade completion, a higher rate of high school graduation, and higher rates of college attendance.

Other program effects included less child maltreatment in the only program that assessed that outcome , fewer arrests by age 19 two programs , higher rates of employment in the two programs that assessed this outcome , and higher monthly earnings assessed by one program. A study of adults who participated in the Abecedarian project also demonstrated reduced levels of depressive symptoms McLaughlin, Campbell, et al.

Temple and Reynolds conclude that the benefits of these programs exceeded their costs. A meta-analysis by Aos, Lieb, and colleagues of these and other early childhood education programs draws a similar conclusion see also Chapter 9. Although Head Start has been cited by CDC as an example of a feasible program that could diminish harm to young children from disadvantaged environments Anderson, Shinn, et al.

Ludwig and Philips report only one recent randomized controlled trial of the program Puma, Bell, et al. The evidence from these studies, considered in the context of other research on the value of early childhood education, points to the likely value of universal access to Head Start for disadvantaged children.

At the same time, given the magnitude of the program, the potential value of conclusive evidence of its effect, and the availability of rigorous experimental methods, it is surprising that more experimental evaluations have not been conducted. Promoting Alternative Thinking Strategies: A Preschool and Elementary School Curriculum. A series of evaluations more As mentioned earlier, child maltreatment, including sexual abuse, is a potent risk factor for emotional and behavioral problems.

Davis and Gidycz report on a meta-analysis of school-based programs aimed at teaching children to avoid and report sexual abuse. These programs led to significant improvement in child knowledge and skills related to sexual abuse prevention. The most effective programs included four or more sessions, active participant involvement such as role play , and behavioral skills training.

However, none of the studies examined effects on the prevalence of abuse, and it is difficult to draw conclusions about potential downstream effects of these programs on the risk for MEB disorders. Many of the target risk factors of preventive interventions are interrelated.

In early elementary school, for example, both aggressive and withdrawn behaviors can co-occur, imparting much higher risk than aggressive behavior alone Kellam, Brown, et al. Depressive symptoms in this period are also associated with poor achievement Kellam, Werthamer-Larsson, et al.

Externalizing behavior across different social fields and deviant peer group contact in middle school predict later juvenile arrest and drug use, and much higher levels of risky sexual behavior are seen among those with both internalizing and externalizing problems Dishion, The life course of those with multiple problem behaviors is especially negatively affected Biglan, Brennan, et al. A variety of school-based interventions have been designed to address risk and protective factors associated with violence, aggression, antisocial behavior, and substance use, primarily in middle school group settings see Chapter 7 for discussion of programs that specifically target substance use and abuse.

Many of these interventions involve social skills training using cognitive components that alter perception and attributions or a curriculum designed to change behaviors to improve social relationships or promote nonresponse to provocative situations. Selective and indicated interventions tend to focus on skill development. A growing body of research shows that many negative outcomes, such as psychopathology, substance abuse, delinquency, and school failure, have overlapping risk factors and a significant degree of comorbidity Feinberg, Ridenour, and Greenberg, Emerging evidence suggests that some programs have positive effects on several of these outcomes Wilson, Gottfredson, and Najaka, Numerous meta-analyses of school-based preventive interventions have been conducted, varying in the specific types of programs included, the age range of the interventions, and the target problems.

All have reviewed one or more outcomes related to antisocial behavior, violence and aggression, or substance abuse and found significant but small to modest effects on measured outcomes. Meta-analyses provide support for the positive effects of behavioral interventions Wilson and Lipsey, ; Mytton, DiGuiseppi, et al. There is some indication that programs combining behavioral and cognitive aspects can impact multiple outcomes, specifically social competence and antisocial behavior Beelmann and Losel, Wilson, Lipsey, and Derzon found significant effects of school-based programs on aggressive behavior.

Wilson and Lipsey conclude that program effects have practical as well as statistical significance and forecast that such programs would lead to a 25—33 percent reduction in the base rate of aggressive problems in an average school. Few programs to date have focused on classroom or behavior management. A meta-analysis that included two such programs found them to have a sizable impact on delinquency Wilson, Gottfredson, and Najaka, There is strong evidence for the long-term effects of at least one classroom intervention, the Good Behavior Game see Box , on aggression and mental health and substance abuse—related outcomes, particularly among boys.

The Good Behavior Game: The Good Behavior Game GBG is a simple universal program to reinforce appropriate social and classroom behavior in elementary school. The theory of the more Preventive interventions can also have a positive effect on academic outcomes, although few studies have measured this outcome Hoagwood, Olin, et al. A meta-analysis of programs that include academic achievement as an outcome concluded that the effects of social and emotional learning programs were equivalent to a 10 percent point gain in test performance Durlak, Weissberg, et al.

Students participating in the program also demonstrated improvements in school attendance, school discipline, and grades.

About prevention and early intervention strategies

Hoagwood, Olin, et al. However, the academic effects were modest and often short-lived.

Reviews of violence prevention initiatives support their efficacy in reducing violence and aggressive behavior Centers for Disease Control and Prevention, ; Hahn, Fuqua-Whitley, et al.

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