|| Bridging Science and Culture to Improve Drug Abuse Research in Minority Communities
This Conference was held at the Wyndham Franklin Plaza hotel in Philadelphia, P.A., September 24-26, 2001.
Elimination of Barriers to Treatment for Women at Risk for HIV
Wendee M. Wechsberg, Ph.D.
Reaching and treating women with substance abuse disorders has been a topic for more than 20 years, yet has the field been successful? Many barriers prevent women from entering treatment, particularly minority women who appear to be at greater risk for HIV. These barriers are either structural (e.g., cost, transportation, day care, gender bias treatment), psychological (e.g., guilt, self-blame, PTSD, depression), or contextual (e.g., homelessness, joblessness, relationship demands) and may prevent treatment programs from both reaching and retaining women. Studies have shown that in addition to many of these barriers, women face such obstacles as fear of losing their children, fear of punishment if they admit their drug problem, and fear of violence from their husbands, boyfriends, or partners. Cultural barriers and expectations that keep women from seeking help are also in play. Although programs discuss strategies for reaching and engaging women into the treatment process, not all women are alike. Therefore, individualized assessments and treatment plans need to be sensitive to a woman's history, living conditions, and her own intrinsic barriers for recovery. Moreover, because treatment programs alone cannot address the scope of women's issues, establishing linkages to other resources and community services will ensure greater opportunity for programs to respond successfully to identified needs.
Issues Affecting the Prevention and Treatment of Substance Abuse in Asian American/Pacific Islander Populations
Ford H. Kuramoto, M.S.W., D.S.W.
The presentation will address the need for substance abuse prevention and treatment research regarding Asian American and Pacific Islander (AAPI) populations in the continental United States, Hawaii, and the Pacific Islands. AAPIs represent many diverse cultures for which specialized research is needed to improve drug abuse prevention, intervention, treatment, and recovery. The existing data sets are inadequate to develop large, detailed studies regarding AAPI populations. A range of research strategies are needed to properly address the individual AAPI populations in an effective manner.
Furthermore, drug abuse research among AAPI populations must consider barriers such as stigma and shame, language and culturally specific belief systems, and the lack of understanding of Western research methods. In many instances, for example, qualitative and formative research is needed to frame relevant research questions. Incidence and prevalence data are needed for epidemiologic data. However, much work is also needed through qualitative methods to identify the patterns of drug use, drugs of choice among specific AAPI populations, and individual drug-abuse histories over time. AAPI prevention and treatment service program strategies should also be identified and disseminated in order to understand the most effective approaches.
Prenatal Exposure to Cocaine: The Collision of Science and Culture
Deborah A. Frank, M.D.
The study of children prenatally exposed to cocaine provides an instructive example of how cultural expectations about race/ethnicity and women's roles can distort the interpretation of scientific data. These distortions have stigmatized children and given rise to public policies toward cocaine-using women (particularly women of color) that violate established canons of medical ethics and civil liberties. Usual standards of methodological rigor have often been ignored in the study of prenatal cocaine exposure. Less than one-half of studies in peer-reviewed journals of post-neonatal outcomes up to age 6 of children with prenatal cocaine exposure meet essential methodological criteria (prospective recruitment, masked assessment, appropriate comparison subjects, and exclusion of subjects exposed in utero to opiates, amphetamines, phencyclidine, or maternal HIV infection). In the studies that do meet these criteria, after controlling for confounders, there is no consistent negative association between prenatal cocaine exposure and physical growth or developmental test scores. Data regarding receptive or expressive language skills are inconsistent, with three studies finding no effect to 36 months, one finding decreased auditory comprehension at 1 year, and one finding no mean differences, but increased "low language scores" on a language sample at 6 years. Less optimal motor scores have been found up to 7 months of age, but not thereafter, and may reflect heavy tobacco exposure. No independent cocaine effects have been shown on standardized parent and teacher reports of child behavior scored by accepted criteria.
Further replication is required of experimental paradigms and novel statistical manipulations of standard instruments that suggest an association between prenatal cocaine exposure and decreased attentiveness and emotional expressivity as well as differences on neurophysiologic measures such as electroencephalogram, heart rate, and baseline cortisol measures, each of which has been found in only one sample. Among children up to 6 years of age, there is no convincing evidence that prenatal cocaine exposure is associated with developmental toxicity different in severity, scope, or kind from the sequelae of multiple other risk factors. Many findings once thought to be specific effects of in utero cocaine exposure are more strongly correlated with other factors, including prenatal exposure to tobacco, marijuana, or alcohol and the quality of the child's environment. However, health providers should not ignore the fact that cocaine use in pregnancy, like other addictions, is often a marker for parents and children at risk for poor health and impaired caregiving due to factors ranging from infectious diseases to domestic violence. From a scientific perspective, much is still unknown, and ongoing followup of exposed children and comparison samples into adulthood is needed. Increasing cognitive demands and social expectations as children mature may unmask sequelae of exposure not previously identified. Cumulative environmental risk and protective variables should also be studied to identify factors that may exacerbate or moderate negative outcomes. Care and study of families affected by substance abuse should be comprehensive and not irrationally shaped by social prejudices that demonize some drugs and drug users, but not others.
Delaney-Black V et al. (2000) Expressive language development of children exposed to cocaine prenatally: Literature review and report of a prospective cohort study. Journal of Communication Disorders 33:463-481.
Frank DA, Augustyn M, Grant Knight W, Pell T, Zuckerman B. (2001) Growth, development, and behavior in early childhood following prenatal cocaine exposure: A systematic review. Journal of the American Medical Association 285:1613-1625.
Singer LT et al. (2001) Developing language skills of cocaine exposed infants. Pediatrics 107:1057-1064.
Effects of Acute Smoked Marijuana on Complex Cognitive Performance
Carl L. Hart, Ph.D.
Although the ability to perform complex cognitive operations is assumed to be impaired following acute marijuana smoking, complex cognitive performance after acute marijuana use has not been adequately assessed under experimental conditions. In the present study, we used a within-participant double-blind design to evaluate the effects of acute marijuana smoking on complex cognitive performance in experienced marijuana smokers. Eighteen healthy research volunteers (8 females, 10 males), averaging 24 marijuana cigarettes per week, completed this three-session outpatient study; sessions were separated by at least 72 hours. During sessions, participants completed baseline computerized cognitive tasks, smoked a single marijuana cigarette (0, 1.8, or 3.9 percent delta-9 THC w/w), and completed additional cognitive tasks. Blood pressure, heart rate, and subjective effects were also assessed throughout sessions. Marijuana cigarettes were administered in a double-blind fashion and the sequence of delta-9 THC concentration order was balanced across participants. Although marijuana significantly increased the number of premature responses and the time participants required to complete several tasks, it had no effect on accuracy on measures of cognitive flexibility, mental calculation, and reasoning. Additionally, heart rate and several subjective-effect ratings (e.g., "Good Drug Effect," "High," "Mellow") were significantly increased in a delta-9 THC concentration-dependent manner. These data demonstrate that acute marijuana smoking produced minimal effects on complex cognitive task performance in experienced marijuana users.
Effective Prevention Strategies and Programs With Minority Communities
Pamela Jumper-Thurman, Ph.D.
This presentation will be a very brief overview of the challenges faced in developing effective prevention and intervention strategies in minority communities. Further, it is necessary to acknowledge that there are differences within each ethnic group that are as great or greater than differences between ethnic and majority groups, and consideration of these differences is critically important in developing successful intervention strategies. Finally, information will be given about current models and programs that have been found to be effective with specific ethnic groups.
Making Prevention Programs Culturally Appropriate: Examples, Challenges, and Needs
Rose Alvarado, Ph.D.
Parenting and other family-based approaches to prevention are critical ingredients in effective approaches to substance abuse prevention. Questions have been raised, however, about the usefulness of universal family-based prevention with culturally diverse families. Little research has been published on how successful universal prevention programs are in attracting, retaining, and impacting families from diverse cultures (Turner, 2000), and there are a limited number of research-based programs developed specifically for ethnic populations (Szapocznik, Kurtines, Santisteban, and Rio, 1990). Although there is substantial overlap in the factors promoting drug use/abuse among different racial or ethnic groups (Epstein, Botvin, Diaz, and Schinke, 1995; Newcomb, 1992), the strength of the influence of etiological factors varies. This suggests more emphasis is needed in other domains (i.e., family) for different ethnic groups.
Because of the dearth of research on culturally adapted or even culturally specific universal family programs, randomized control trials are needed to develop and test culturally appropriate versions of the major evidence-based, universal family programs. Applied research is also required to determine whether these new culturally adapted versions will work with other ethnic subgroups. Once questions of how to best strengthen multiethnic families are answered, we will be well equipped to reduce substance abuse.
Epstein JA, Botvin GJ, Diaz T, Schinke SP. (1995) The role of social factors and individual characteristics in promoting alcohol among inner-city minority youth. Journal of Studies on Alcohol 56:39-46.
Newcomb MD. (1992) Understanding the multidimensional nature of drug use and abuse: The role of consumption, risk factors, and protective factors. In M.D. Glantz, R. Pickens (eds.), Vulnerability to Drug Abuse. Washington, D.C.: American Psychological Association, pp. 255-297.
Szapocznik J, Kurtines W, Santisteban DA, Rio AT. (1990) The interplay of advances among theory, research and application in treatment interventions aimed at behavior problem children and adolescents. Journal of Consulting and Clinical Psychology 58:696-703.
Turner W. (2000) Cultural considerations in family-based primary prevention programs in drug abuse. In S. Kaftarian, K.L. Kumpfer (guest eds.). Special Section: Family-focused Research and Primary Prevention Practices. Journal of Primary Prevention 21(3):285-303.
Free to Grow: Translating Substance Abuse Research Into Preventive Practice in a National Head Start Initiative
Judith E. Jones, M.Sc.
This presentation will describe the application of research on risk and protective factors as employed in the design and strategies of a substance abuse prevention initiative in partnership with the national Head Start program, the Nation's largest early childhood program serving low-income and minority children. In the absence of a large body of research-based model programs aimed at decreasing children's vulnerability to substance abuse and other high-risk behaviors as they grow older, the goal of the initiative, which is supported by The Robert Wood Johnson Foundation, is to demonstrate how preventive research can be applied in the early childhood period by strengthening the immediate environment of the young child. While the findings from phase I of the initiative demonstrate the applicability of theory and research to practice, they do not provide sufficient evidence to determine whether these inputs will result in intermediate and long-term outcomes that prove whether early intervention is the answer to ATOD use and abuse as children age into adolescence. Moreover, the challenges of using the risk and protective factors framework to guide model development and adaptation should not be underestimated, because the interrelationships are not yet well established. However, lessons learned in the pilot phase are sufficiently promising that a research and program demonstration has just been launched in 18 diverse Head Start sites across the Nation. This phase of the initiative will undergo a rigorous process and outcome evaluation that will examine the impact of Free to Grow on the families and neighborhoods targeted by the program in order to provide a better understanding of "what works under what circumstances" to ensure the healthy development of the young child.
Key questions that require further research include the following: Do Free to Grow programs reduce known risk factors and increase protective factors among participating families? Are participating families more likely to resist abusing alcohol and other drugs? Do the Free to Grow interventions produce more stable and productive living environments? Is the Head Start program a viable vehicle for addressing substance abuse prevention?
Hawkins JD, Catalano RF, Miller JY. (1992) Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin 112(1):64-105.
Kumpfer KL. (1991) How to get hard-to-reach parents involved in parenting programs. In E.M. Johnson, G.A. Held, R.W. Denniston (eds.), Parent Training Is Prevention: Preventing Alcohol and Other Drug Problems Among Youth in the Family. Washington, D.C.: U.S. Government Printing Office, pp. 87-95.
Yoshikawa H. (1994) Prevention as cumulative protection: Effects of early family support and education on chronic delinquency and its risks. Psychological Bulletin 115(1):28-54.
Effective Treatment With Minority Communities
José Szapocznik, Ph.D.
Adolescent drug abuse is often part of a larger syndrome of problem behaviors that reflect an antisocial developmental trajectory for the youth. Research shows that there are a number of important ecological influences on the adolescent, the most significant and proximal of which is the family. Research on family intervention has demonstrated the efficacy of family-based interventions in bringing about reductions in risk and promotion of protection in the minority adolescent and her/his ecology.
Drug Treatment Services for Minority Populations
Andrea G. Barthwell, M.D., FASAM
This presentation provides descriptions of cultural interactions between and among individuals and the basis for the cultural bias. Using her experiences as a treatment provider who strives to apply evidence-based principles in a variety of treatment settings, Dr. Barthwell will outline cultural interactions that operate in the treatment setting and introduce barriers to participation, motivation, and performance. Finally, research implications and gaps in the literature will be discussed.
Working With Rural African American Youth
Murelle G. Harrison, Ph.D.
The proposed prevention program is based on a heuristic model of family processes through which rural African American youths are hypothesized to develop self-regulation and emotional regulation, increasing the likelihood that they will achieve academically, exhibit few conduct problems, and be accepted by non-deviant peers. Such academic and psychosocial competence is hypothesized to be linked with lower levels of substance use. The model is based on Bandura's (1989) theories on the development of self-efficacy and self-regulatory processes as well as other theories concerning the linkages between self-regulation and substance misuse (Miller and Brown, 1991; Sher and Tull, 1994). The selection of specific family processes for inclusion as prevention targets was based on Brody's research (Brody et al., 1999; Brody et al., 1998), in which a similar model was tested with two-parent and single-parent African American families in rural Georgia. Predictable and routinized home environments have been found to promote youth's internalization of goal-setting, planning, and general self-organization, which in turn promote academic and psychosocial adjustment and deter substance use.
Barriers that must be overcome in working with rural African American families include distance from the university, low density of population, and suspiciousness of families concerning participation. Identifying representative rural populations often requires traveling long distances from the university, resulting in higher cost and expenditure of time. Low population density of rural areas requires larger areas to secure adequate sample size. Finally, rural African American families are not likely to have been previously approached to participate in a research project or to be knowledgeable about research in general, subsequently arousing suspiciousness, directed especially toward a socially stigmatized content area such as substance abuse.
Further research is needed to determine the influence of siblings on the development of psychosocial and academic competencies and subsequent lower substance use.
Brody GH, Flor DL, Hollett-Wright N, McCoy JK. (1998) Children's development of alcohol use norms: Contributions of parent and sibling norms, children's temperaments, and parent-child discussions. Journal of Family Psychology 12:209-219.
Brody GH, Flor DL, Hollett-Wright N, McCoy JK, Donovan, J. (1999) Parent-child relationships, child temperament profiles, and children's alcohol use norms. Journal of Studies on Alcohol.
Brody GH, Neubaum E, Boyd GM, Dufour M. (1997) Health consequences of alcohol use in rural America. In E.B. Robertson, Z. Sloboda, G.M. Boyd, L. Beatty, N.J. Kozel (eds.), Rural Substance Abuse: State of Knowledge and Issues. National Institute on Drug Abuse Research Monograph 168. NIH Pub. No. 97-4177. Washington, DC: Superintendent of Documents, U.S. Government Printing Office, pp. 137-174.
Working and Conducting Research Among American Indian Families
Jerry Stubben, Ph.D.
This session will focus on the political, social, economic, psychological, and spiritual issues that one may face, whether Native American or non-Native, in a tribal or urban Indian community.
Prevention of HIV Among Adolescents
Mary Jane Rotheram-Borus, Ph.D.
Adolescents are at risk for HIV primarily through their sexual behavior. A comprehensive prevention strategy includes a national HIV campaign based on social-marketing principles; targeted social-marketing, intensive skill-building, and sexually transmitted disease control programs for youth at high risk; programs targeting institutions (e.g., school health clinics), providers, and parents; and interventions to identify and reduce risk acts among seropositive youth. The U.S. focus for HIV prevention has been single-session educational classes (an ineffective strategy) or intensive multisession, small-group interventions for youth at high risk (demonstrated to increase condom use by about 30 percent). There is a need to expand the range, modalities, and dissemination of HIV prevention programs nationally; to recognize (especially by policymakers) limitations of abstinence programs; and to increase early detection of HIV among youth.
Rotheram-Borus MJ. (1997) Interventions to reduce heterosexual transmission of HIV. In NIH Consensus Development Conference on Interventions to Reduce HIV Risk Behaviors: Program and Abstracts [online]. Available: http://consensus.nih.gov/1997/1997PreventHIVRisk104html.htm.
Rotheram-Borus MJ, Lee MB, Murphy DA, Futterman D, Duan N, Birnbaum J, and the Teens Linked to Care Consortium. (2001) Efficacy of a preventive intervention for youth living with HIV. American Journal of Public Health 91:400-405.
Rotheram-Borus MJ, O'Keefe Z, Kracker R, Foo H.-H. (2000) Prevention of HIV among adolescents. Prevention Science 1(1):15-30.
The Prime Time Project
Eric W. Trupin, Ph.D.
In Washington State, the number of violent crimes committed by adolescents ages 10-17 years has doubled since 1981. Adolescents now commit almost one-half of all violent crimes statewide. Because juveniles who commit repeat or violent crimes are the most likely to continue their criminal behavior into adulthood, targeting interventions at juvenile offenders is crucial to the reduction of community violence.
Young offenders are challenging to treat because they often have, in addition to their criminal histories, high rates of mental disorder and substance abuse. In fact, as many as 70 percent of incarcerated youth abuse substances or are dependent on them. The number of African American youth within the juvenile justice system has increased markedly—nearly one-half of juveniles in custody in public facilities in 1990 were African American compared with one-third in 1977.
Many adolescents who fit this profile are seen repeatedly at the county's Juvenile Detention Center, a secure facility that houses youth prior to adjudication and/or sentencing, youth who have been adjudicated and are returning for court appearances, and youth with less than 30-day sentences. In 1994, 11,000 youth were referred to the juvenile court and there were 5,561 admissions to the Detention Center. Given current staffing and the large population, the focus is on assessment and adaptation to the facility rather than treatment.
In 1995, the King County Council funded the Prime Time Project to treat juvenile offenders (12-17 years old) with mental illness and problems with drug/alcohol abuse. The Prime Time Program employs a thorough initial evaluation to identify strengths and problem areas and intensive counseling and case management aimed at building skills, strengthening support, and coordinating all services to the youth and their families. Multisystemic Therapy, which usually takes place in the home, focuses on reducing conflict, supporting the role of parents and caretakers, and increasing the social supports provided by neighbors, churches, and other community resources. Individual counseling employing the techniques developed in Dialectic Behavior Therapy and Motivational Enhancement Therapy are utilized to address the co-occurring disorders of mental illness (e.g., anger management, communication, and impulse control) and substance-abusing behaviors. The counselor also works closely with schools, probation and police officers, and substance abuse treatment programs and helps the youth and their families develop positive, satisfying community activities (jobs, recreation, community service). This program is unique in its intensive involvement at the community level with offenders and every aspect of their lives.
The goals are to keep youth out of detention, reduce antisocial behavior, and increase school attendance and performance. Preliminary results are encouraging, and further research is being conducted to assess outcomes of this innovative intervention.