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Director's Report to the National Advisory Council on Drug Abuse - September, 2010

Research Findings - Prevention Research

Twelve-Year Follow-up of Prenatal Nurse Home Program: Enduring Effects on Mothers and Children

These two studies report on the 12-year follow-up outcomes of a randomized trial of prenatal and infancy nurse home visiting (Nurse Family Partnership), conducted with an urban primarily African American sample of first time mothers and their firstborn children. Participants were recruited through a public system of obstetric and pediatric care in Memphis, Tennessee. A total of 594 urban primarily African American economically disadvantaged mothers (among 743 who registered during pregnancy) enrolled in the study and were randomized to receive the nurse home visiting intervention or to a control group. Mothers in the control condition (n=515) were provided free transportation for scheduled prenatal care plus developmental screening and referral services for their child at age 6, 12, and 24 months. Mothers in the nurse-visited condition (n=228) were provided the same services as those in the control group plus prenatal and infancy home visiting through their child's second birthday. Combined, these two studies demonstrate the importance and value of long-term follow-up for determining the impact of early intervention approaches on families and their children.

  • Positive Impact on Maternal Life Course and Government Spending This study focused on mothers' fertility, partner relationships, economic self-sufficiency, and on government spending through age 12 years of the target child. Specifically, they measured mothers' cohabitation with and marriage to the child's biological father, intimate partner violence, duration (stability) of partner relationships, role impairment due to alcohol and other drug use, use and cost of welfare benefits, arrests, mastery, child foster care placements, and cumulative subsequent births. By the time the firstborn child was 12 years old, nurse-visited mothers compared with control subjects reported less role impairment owing to alcohol and other drug use (0.0% vs 2.5%, P = .04), longer partner relationships (59.58 vs 52.67 months, P = .02), and greater sense of mastery (101.04 vs 99.60, P = .005). During this 12-year period, government spent less per year on food stamps, Medicaid, and Aid to Families with Dependent Children and Temporary Assistance for Needy Families for nurse-visited than control families ($8772 vs $9797, P = .02); this represents $12,300 in discounted savings compared with a program cost of $11,511 (both expressed in 2006 US dollars). No statistically significant program effects were noted on mothers' marriage, partnership with the child's biological father, intimate partner violence, alcohol and other drug use, arrests, incarceration, psychological distress, or reports of child foster care placements. The authors conclude that the program improved maternal life course and reduced government spending among children through age 12 years. Olds D, Kitzman H, Cole R, Hanks C, Arcoleo K, Anson E, Luckey D, Knudtson M, Henderson C, Bondy J, Stevenson A. Enduring Effects Of Prenatal And Infancy Home Visiting By Nurses On Maternal Life Course And Government Spending: Follow-Up Of A Randomized Trial Among Children At Age 12 Years. Arch Pediatr Adolesc Med. 2010; 164(5): 419-424.
  • Positive Impact on Children's Substance Use, Internalizing Problems and Academic Achievement This study reports on the12-year-old, firstborn children's use of substances, behavioral adjustment, and academic achievement. Primary outcomes focused on use of cigarettes, alcohol, and marijuana; internalizing, externalizing, and total behavioral problems; and academic achievement. By the time the firstborn child was 12 years of age, those visited by nurses, compared with those in the control group, reported fewer days of having used cigarettes, alcohol, and marijuana during the 30-day period before the 12-year interview (0.03 vs 0.18, P = .02) and were less likely to report having internalizing disorders that met the borderline or clinical threshold (22.1% vs 30.9%, P = .04). Nurse-visited children born to mothers with low psychological resources, compared with their control group counterparts, scored higher on the Peabody Individual Achievement Tests in reading and math (88.78 vs 85.70, P = .009) and, during their first 6 years of education, scored higher on group-administered standardized tests of math and reading achievement (40.52 vs 34.85, P = .02). No statistically significant program effects were found on children's externalizing or total behavioral problems. This study demonstrates that an early intervention, can have a long-term impact, in this case, on children's use of substances and internalizing mental health problems, improvements in academic achievement of children born to mothers with low psychological resources at baseline. Kitzman H, Olds D, Cole R, Hanks C, Anson E, Arcoleo K, Luckey D, Knudtson M, Henderson C, Holmberg J. Enduring Effects Of Prenatal And Infancy Home Visiting By Nurses On Children: Follow-Up Of A Randomized Trial Among Children At Age 12 Years. Arch Pediatr Adolesc Med. 2010; 164 (5): 412-418.

Fast Track Preventive Intervention Associated with Reduced Use of Health Services 12 Years Later

This analysis tested the impact of the Fast Track conduct disorder prevention program on the use of pediatric, general health, and mental health services in adolescence. Participants were 891 public kindergarten boys and girls screened from a population of 9594 children and found to be at risk for conduct disorder. They were assigned randomly (by school) to intervention or control conditions and were followed for 12 years. The final sample included 891 children divided into intervention (n = 445) and control groups (n = 446) and equally spread among sites (Durham, NC: n = 219; Nashville, TN: n = 230; Central, PA: n = 225; Seattle, WA: n = 217). Across all sites, the sample primarily comprised black and white participants (51% black, 47% white, and 2% of other ethnicity) and gender mixed (69% boys). The sample was skewed toward socioeconomic disadvantage: 58% were from single parent families and 40% of the families were in the lowest socioeconomic class. The intervention lasted 10 years and included parent training, child social-cognitive skills training, reading tutoring, peer-relations enhancement, and classroom curricula and management. Service use was assessed through annual interviews of parents and youth. Youth assigned to receive the preventive intervention had significantly reduced use of professional general health, pediatric, and emergency department services relative to control youth on the basis of parent-report data. For control-group youth, the odds of greater use of general health services for any reason and general health services use for mental health purposes were roughly 30% higher and 56% higher, respectively. On the basis of self-report data, the intervention reduced the likelihood of outpatient mental health services among older adolescents for whom odds of services use were more than 90% higher among control-group youth. No differences were found between intervention and control youth on the use of inpatient mental health services. Statistical models controlled for key study characteristics, and potential moderation of the intervention effect was assessed. This investigation indicates that random assignment to the Fast Track prevention program was associated with reduced use of general health and outpatient mental health services in adolescents. Jones D, Godwin J, Dodge K, Bierman K, Coie J, Greenberg M, Lochman J, McMahon R, Pinderhughes E. Impact Of The Fast Track Prevention Program On Health Services Use By Conduct-Problem Youth. Pediatrics. 2010; 125(1): e130-e136.

Long-Term Effects of the Strong African American Families Program on Youth Alcohol Use

This report extends earlier accounts by addressing the effects of the Strong African American Families (SAAF) preventive intervention program across 65 months (approximately 5 years and 4 months). Two hypotheses were tested: (a) Rural African American youths randomly assigned to participate in SAAF would demonstrate lower rates of alcohol use than would control youths more than 5 years later, and (b) SAAF's effects on deterring the onset of alcohol use in early adolescence would carry forward to mediate the program's long-term effects. African American youths in rural Georgia (mean age at pretest = 10.8 years; 53% girls) were assigned randomly to the SAAF group (n = 369) or to a control group (n = 298). Past-month alcohol use was assessed at pretest and at 9, 18, 29, 53, and 65 months after pretest. SAAF participants increased their alcohol use at a slower rate than did adolescents in the control condition across the follow-up assessments. At the 65-month assessment, SAAF participants reported having drunk alcohol half as often as did youths in the control group. Consistent with the second hypothesis, SAAF's effects on deterring initiation carried forward to account for its effects on alcohol use across time. This research indicates that training in protective parenting processes and self-regulatory skills during preadolescence may contribute to a self-sustaining trajectory of disinterest in and avoidance of alcohol use during adolescence when peers begin to model and sanction it. Brody G, Chen Y, Kogan S, Murry V, Brown A. Long-Term Effects Of The Strong African American Families Program On Youths' Alcohol Use. J Consult Clin Psychol. 2010; 78(2): 281-285.

Impact of Brief Image-Based Preventive Intervention is Greatest for Drug-using Adolescents

This study evaluated the efficacy of a brief image-based prevention intervention and assessed current drug use as a moderator of intervention effects. In a clinical trial, 416 high school-age adolescents were randomized to either the brief intervention or usual care control. Data were collected at baseline and 3-month follow-up. The brief intervention consisted of a tailored in-person communication (i.e., screening survey, consultation, and goal plan) that occurred during regular school hours and was followed up one week later by a 3-week series of parent/guardian print materials comprised of tailored messages that paralleled those in the consultation. Health behavior goal setting increased for participants receiving the brief intervention, with an effect size in the small range (d = 0.33). Overall effect sizes for cigarette smoking frequency and quantity and alcohol use frequency and quantity were small (ds = 0.16-0.21) and in favor of the brief intervention. However, adolescents reporting current substance use who received the brief intervention reduced their frequency and heavy use of alcohol, frequency and quantity of cigarette smoking, and reported fewer alcohol/drug problems, with larger effects ranging from small to approaching medium in size (ds = 0.32-0.43, ps < .01). The findings from this study suggest that brief image-based messages may increase health behavior goal setting and reduce substance use in high school-age adolescents, particularly among those using drugs. Werch C, Bian H, Diclemente C, Moore M, Thombs D, Ames S, Huang I, Pokorny S. A Brief Image-Based Prevention Intervention For Adolescents. Psychol Addict Behav. 2010; 24(1): 170-175.

15 Minutes with a Video Doctor and Provider Cueing Reduces Smoking among Pregnant Women

This study examined the use of a Video Doctor plus provider cueing to promote provider advice and smoking cessation outcomes in pregnancy, through a randomized controlled trial conducted from 2006 to 2008. Five community prenatal clinics in the San Francisco Bay Area of the United States were recruited for the trial. A total of 410 pregnant patients in these clinics completed screening for behavioral risks including tobacco use in the past 30 days. Pregnant smokers (n = 42) were identified and randomized regardless of their intention to quit smoking. Participants were assigned to either usual care or to the Video Doctor intervention. Intervention participants received a 15-minute Video Doctor session. The Video Doctor delivered interactive tailored messages, an educational worksheet for participants and a cueing sheet for providers. The main outcomes focused on receipt of advice from the provider and 30-day smoking abstinence, both by self-report. Results indicated that intervention participants were more likely to receive provider advice on tobacco use at both prenatal visits during the intervention period (60.9 % vs. 15.8%, p = 0.003). The intervention yielded a significantly greater decrease in the number of days smoked and in cigarettes smoked per day. Although not statistically significant, the 30-day abstinence rate at two months post baseline was 2.5 times greater in the intervention group (26.1% vs. 10.5%, p = 0.12). The authors conclude that the Video Doctor plus provider cueing is an efficacious adjunct to routine prenatal care by promoting provider advice and smoking reduction among pregnant smokers. Tsoh J, Kohn M, Gerbert B. Promoting Smoking Cessation In Pregnancy With Video Doctor Plus Provider Cueing: A Randomized Trial. Acta Obstet Gynecol Scand. 2010; 89(4): 515-523.

Effects of a Social and Emotional Learning Program on Aggression, Prosocial Behavior and Academic Engagement in Children

This article examines the impact of a universal social-emotional learning program, the Fast Track PATHS (Promoting Alternative Thinking Strategies) curriculum and teacher consultation, embedded within the Fast Track selective prevention model. The longitudinal analysis involved 2,937 children of multiple ethnicities who remained in the same intervention or control schools for Grades 1, 2, and 3. The study involved a clustered randomized controlled trial involving sets of schools randomized within 3 U.S. locations (i.e., rural Pennsylvania, Seattle, & Nashville). Measures assessed teacher and peer reports of aggression, hyperactive-disruptive behaviors, and social competence. Beginning in first grade and through 3 successive years, teachers received training and support and implemented the PATHS curriculum in their classrooms. The study examined the main effects of intervention as well as how outcomes were affected by characteristics of the child (baseline level of problem behavior, gender) and by the school environment (student poverty). Modest positive effects of sustained program exposure included reduced aggression and increased pro-social behavior (according to both teacher and peer report) and improved academic engagement (according to teacher report). Peer report effects were moderated by gender, with significant effects only for boys. Most intervention effects were moderated by school environment, with effects stronger in less disadvantaged schools, and effects on aggression were larger in students who showed higher baseline levels of aggression. The authors conclude that a major implication of the findings is that well-implemented multiyear social-emotional learning programs can have significant and meaningful preventive effects on the population-level rates of aggression, social competence, and academic engagement in the elementary school years. The Effects Of A Multiyear Universal Social-Emotional Learning Program: The Role Of Student And School Characteristics. Conduct Problems Prevention Research Group. J Consult Clin Psychol. 2010; 78(2): 156-168.

Initial Findings from the Dissemination of Project Toward No Drug Abuse into Real-World Conditions

This study describes the immediate outcomes of a dissemination and implementation trial of Project Toward No Drug Abuse (TND), an evidence-based prevention program for high school students. A total of 65 high schools in 14 school districts across the USA were recruited and randomly assigned to one of three experimental conditions: comprehensive implementation support for teachers implementing TND, regular workshop training only for teachers implementing TND, or standard care control where TND was not implemented. The comprehensive intervention was comprised of on-site coaching, web-based support, and technical assistance, in addition to the regular workshop. It was hypothesized that this comprehensive training and support model compared to standard pre-implementation training workshops would result in higher implementation fidelity and improved student outcomes. High school students (mean age = 14.8 years; SD = 1.0 years) (n = 2,983) completed self-report surveys before and immediately after program implementation. Fidelity of implementation was assessed with a classroom observation procedure that focused on program process. Results indicated that relative to the controls, both intervention conditions produced effects on hypothesized program mediators, including greater gains in program-related knowledge; greater reductions in cigarette, marijuana and hard drug use intentions; and more positive changes in drug-related beliefs. There were stronger effects on implementation fidelity in the comprehensive, relative to the regular, training condition. However, seven of the ten immediate student outcome measures showed no significant differences between the two training conditions. These results suggest that comprehensive training approaches may improve implementation fidelity, but these improvements in fidelity may not result in stronger program outcomes. In sum, these findings contribute to a small, but growing, body of evidence for the effectiveness of school-based substance abuse prevention programs that have been tested under real-world conditions. Rohrbach L, Gunning M, Sun P, Sussman S. The Project Towards No Drug Abuse (TND) Dissemination Trial: Implementation Fidelity And Immediate Outcomes. Prev Sci. 2010; 11(1): 77-88.

Addressing Selection Effects In Drug Abuse Prevention Interventions Delivered Under Real World Circumstances

This study focused on improving the estimates of the costs and benefits of substance abuse through identification and correction of selection effects in community-implemented interventions. A supplemental comparison sample is typically used for this purpose, but in community-based program implementations, such a sample is often not available. The authors present an evaluation design and analytic approach that can be used in program evaluations of real-world implementations to identify selection effects, which in turn can help inform recruitment strategies, pinpoint possible selection influences on measured program outcomes, and refine estimates of program costs and benefits. The approach is illustrated with data from a multisite implementation of a popular substance abuse, family-based, prevention program. Results indicate that the program's participants differed significantly from the population at large-having a female child and being of White race/ ethnicity were associated with greater participation of families with younger adolescents. Families with highest levels of opportunity for positive family interaction were less likely to participate. Weaker family management skills, lower levels of adolescent drug use, and Latino or American Indian/Alaska Native ethnicity were all associated with greater participation of families with older youth. Taken together, these findings demonstrate that there were selection effects in this community-based implementation of an evidence-based practice. Hill L, Goates S, Rosenman R. Detecting Selection Effects In Community Implementations Of Family-Based Substance Abuse Prevention Programs. Am J Public Health. 2010; 100(4): 623-630.

Generally Healthy Behaviors are Diminished Among Multigenerational Caregivers

The current study examined the association between membership in the "sandwich" generation, defined as providing care to both children and parents or in-laws, and five health behaviors: checking the food label for health value when buying foods, using a seat belt, choosing foods based on health value, exercising regularly, and cigarette smoking. Participants were from the Indiana University Smoking Survey, an ongoing cohort-sequential study of the natural history of cigarette smoking. Between 1980 and 1983, all consenting 6th-12th graders in a Midwestern county school system completed annual surveys. The total sample size of those who were assessed at least once was 8487. Follow-up surveys were conducted in 1987, 1993, 1999, and 2005. Because the sample is 96% non-Hispanic Caucasian, ethnic differences are not considered. Demographically, the sample is similar to the community from which it was drawn. For example, the marriage rate is 64% in this sample compared to 66% among similarly aged adults in the Midwest, and the high school graduation rate is 97% in this sample compared to 92% among similarly aged adults in the Midwest. At the most recent follow-up conducted in 2005, the smoking rate in the sample was 23% compared to a 2006 statewide rate of 24% and regional rate of 17%. For the current study, participants were selected from the most recent follow-up survey (2005) who provided data on the number of hours per week spent providing unpaid help to their children, to their parents or the people who raised them, and to their in-laws. This yielded a sample of 4943 (mean age = 37.8, SD = 2.7, range 32-47. Although there is great variability in the definition of midlife, with age boundaries ranging from 30 to 60, this sample might best be considered to represent entry into midlife. Regression analyses tested the unique effect of sandwich generation membership on health behaviors above and beyond demographic factors and prior levels of the same behavior. Compared to other caregivers and non-caregivers, multigenerational caregivers were less likely to check food labels and to choose foods based on health values. Multigenerational caregivers were less likely than non-caregivers and those who cared for children only to use seat belts, and they smoked marginally more cigarettes per day than those groups. Multigenerational caregivers were less likely than non-caregivers and those who cared for parents/in-laws only to exercise regularly. Thus, in general, healthy behaviors were diminished for multigenerational caregivers. Chassin L, Macy JT, Seo D, Presson CC, Sherman SJ. The Association Between Membership In The Sandwich Generation And Health Behaviors: A Longitudinal Study. J Appl Dev Psychol. 2010; 31(1): 38-46.

Person-Centered Modeling Approach Reveals Risk Factors for Negative Child Outcomes

This study relied on data from Fast Track, a multisite, multi-cohort research project designed to study and change the development of serious conduct problems among aggressive children. This study included children and their families from the schools assigned to the control condition in Fast Track. Fast Track recruited children and families from four distinct communities in the United States. These communities were (a) Durham, North Carolina, a small city with many low- to middle- socioeconomic status (SES) African American families; (b) Nashville, Tennessee, a moderate-sized city with many low- to middle-SES African American and European American families; (c) Seattle, Washington, a moderate-sized city with many low- to middle-SES, ethnically diverse families, including European Americans, African Americans, Asian and Pacific Islanders, Latinos, and Native Americans; and (d) Central Pennsylvania, a rural area with mostly low- to middle-SES, two-parent, European American families. Fifty-eight percent of the children in this sample were male, and 42% were female. At the beginning of the study, children were an average of 6 years, 5 months old (SD = 5 months). At the end of this study, they were 5 years older. This study identified profiles of 13 risk factors across child, family, school, and neighborhood domains in a diverse sample of children in kindergarten from four US locations (n = 750; 45% minority). It then examined the relation of those early risk profiles to externalizing problems, school failure, and low academic achievement in Grade 5. A person-centered approach, latent class analysis, revealed four unique risk profiles, which varied considerably across urban African American, urban White, and rural White children. Profiles characterized by several risks that cut across multiple domains conferred the highest risk for negative outcomes. Compared to a variable-centered approach, such as a cumulative risk index, these findings provide a more nuanced understanding of the early precursors to negative outcomes. For example, results suggested that urban children in single-parent homes that have few other risk factors (i.e., show at least average parenting warmth and consistency and report relatively low stress and high social support) are at quite low risk for externalizing problems, but at relatively high risk for poor grades and low academic achievement. These findings provide important information for refining and targeting preventive interventions to groups of children who share particular constellations of risk factors. Lanza S, Rhoades B, Nix R, Greenberg M. Modeling The Interplay Of Multilevel Risk Factors For Future Academic And Behavior Problems: A Person-Centered Approach. Dev Psychopathol. 2010; 22(2): 313-335.

Use of Text Messaging to Contact Difficult-to-Reach Study Participants

The authors investigated use of text messaging for contacting study participants expected to be difficult to reach. The authors pilot tested a program that trained secondary exchangers - methamphetamine injectors who frequent a syringe exchange program and regularly provide syringes to others- to be peer educators who delivered HIV risk reduction messages to methamphetamine-injecting recipients who do not regularly attend syringe exchange programs. The evaluation involved baseline and 3-month follow interviewers with recipients identified by secondary exchangers. Forty-eight (75%) of 64 recipients who were eligible completed a baseline interview. All of these participants reported having injected methamphetamine within the past 60 days. Their drug use and other characteristics suggested that they would be difficult to reach. Text messaging was an important way to reach enrolled participants during the study. Thirty-five (73%) indicated text messaging was a way to reach them. Generally, study staff first tried to reach participants by calling them, and then tried text messaging, if possible. Staff attempted to reach 15 (31%) of the 48 enrolled participants by text messaging, and 8 of them (53%) responded to the text. Text messaging was the only way for staff to contact 3 participants at least 1 point during the study. Overall, 43 (90%) of the 48 enrolled participants completed 3-month follow-up interviews. Text messaging was an acceptable means of communication for study participants and much cheaper than in-person field visits to participants. Given the authors' success with text messaging and its extensive use, they recommend other studies consider using it as part of their comprehensive tracking protocol for contacting populations expected to be difficult to reach. Maher J, Pranian K, Drach L, Rumptz M, Casciato C, Guernsey J. Using Text Messaging To Contact Difficult-To-Reach Study Participants. Am J Public Health. 2010; 100(6): 969-970.

How Prenatal Care Providers Approach Counseling about Excessive Weight Gain in Pregnancy

Excessive weight gain during pregnancy is becoming more common and is associated with many adverse maternal and infant outcomes. There is a paucity of data on how weight gain counseling is actually provided in prenatal care settings. This qualitative study focused on prenatal care providers and their knowledge, attitudes, and practices regarding prevention of excessive weight gain during pregnancy and, secondarily, their approach to nutrition and physical activity counseling during pregnancy. Seven focus groups were conducted with general obstetrician/ gynecologists, midwives, and nurse practitioners. Providers agreed to participate because they were unsure of the effectiveness of their counseling efforts and wanted to learn new techniques for counseling patients about weight gain, nutrition, and physical activity. Several barriers to weight gain counseling were identified, including insufficient training, concern about the sensitivity of the topic, and the perception that counseling is ineffective. Providers all agreed that weight gain was an important topic with short-term and long-term health consequences, but they described widely disparate counseling styles and approaches. The authors conclude that prenatal care providers are deeply concerned about excessive weight gain and its sequelae in their patients but encounter barriers to effective counseling. Moreover, findings indicate that providers want new tools to help them address weight gain counseling during pregnancy. Stotland N, Gilbert P, Bogetz A, Harper C, Abrams B, Gerbert B. Preventing Excessive Weight Gain In Pregnancy: How Do Prenatal Care Providers Approach Counseling? J Womens Health. 2010; 19(4): 807-814.


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