The causal effect of resilience on risk for drug abuse: a Swedish national instrumental variable, co-relative and propensity-score analysis.

BACKGROUND: We sought to quantify and investigate the causal nature of the association between resilience at age 18 and future drug abuse (DA). METHOD: In a national sample of Swedish men (n = 1 392 800), followed for a mean of 30.3 years, resilience was assessed during military conscription and DA defined from medical, criminal and pharmacy registers. For causal inference, we utilized three methods: (i) instrumental variable analyses with the month of birth as the instrument; (ii) co-relative analyses using the general population, cousins, siblings and monozygotic twins; and (iii) propensity scoring on a subsample (n = 48 548) with strong resilience predictors. Cox proportional hazards models were utilized to examine survival time till DA diagnosis. RESULTS: Low resilience was most robustly predicted from internalizing symptoms. Lower levels of standardized resilience strongly predicted the risk for DA (HR = 2.31, 95% CIs 2.28-2.33). In instrumental, co-relative, and propensity score analyses, the association between resilience and DA was estimated at HR = 3.06 (2.44-3.85), 1.34 (1.28-1.39), and 1.40 (1.28-1.53), respectively. Sensitivity analyses suggested that our instrument was weak and, despite our large sample, likely under-estimated confounding. CONCLUSIONS: Low resilience strongly predicts DA risk. Three different causal analysis methods, with divergent assumptions, concurred in estimating that an appreciable proportion of this association was causal, probably around 40%, with the remainder arising from confounding variables many of which are likely familial. Consistent with prior interventions focused on substance use prevention, our results suggest that prevention programs that increase resilience in adolescence should meaningfully reduce the long-term risk for DA.

Evidence for a Causal Relationship Between Academic Achievement and Cigarette Smoking.

INTRODUCTION: Academic achievement (AA) is associated with smoking rates. Can we determine the degree to which this relationship is likely a causal one? METHODS: We predict smoking in male conscripts (mean age 18.2) assessed from 1984 to 1991 (N = 233 248) and pregnant females (mean age 27.7) receiving prenatal care 1972-1990 (N = 494 995) from AA assessed in all students at 16. Instrumental variable (IV) analyses used the instrument month-of-birth as in each school year, older children have high AA. Co-relative analyses used AA-smoking associations in the population, cousins and siblings to predict the AA-smoking relationship in MZ twins, thereby controlling for familial confounding. RESULTS: In males, higher AA was associated with a substantial decrease in risk for smoking (odds ratio [OR] [95% confidence intervals [CIs]] per standard deviation [SD] = 0.41 [0.40-0.41]) while the parallel figures obtain from our IV and co-relative analyses were 0.47 (0.39-0.57) and 0.51 (0.43-0.60), respectively. In females, these figures for pre-pregnancy smoking were, respectively, 0.39 (0.39-0.39), 0.50 (0.46-0.54) and 0.54 (0.51-0.58). Results for heavy versus light smoking suggested a causal effect but were inconsistent across methods. However, among females smoking prior to pregnancy, AA predicted a reduced risk for continued smoking with ORs for uncontrolled, IV, and co-relative analyses equaling, respectively, were 0.54 (0.53-0.55) 0.68 (0.56-0.82) and 0.78 (0.66-0.91), respectively. CONCLUSIONS: Two different methods produced consistent evidence that higher AA has a causal effect on reducing smoking rates and increasing cessation rates in smoking pregnant females. Improving AA may result in meaningful gains in population health through reduced smoking. IMPLICATIONS: This study provides consistent evidence across two different methods that high AA is causally related to reduced rates of smoking and increasing rates of smoking cessation among pregnant women. Our results suggest that interventions that improve educational achievement in adolescence would reduce tobacco consumption, thereby improving public health.

Scaling up Evidence-Based Interventions in US Public Systems to Prevent Behavioral Health Problems: Challenges and Opportunities.

A number of programs, policies, and practices have been tested using rigorous scientific methods and shown to prevent behavioral health problems (Catalano et al., Lancet 379:1653-1664, 2012; National Research Council and Institute of Medicine, 2009). Yet these evidence-based interventions (EBIs) are not widely used in public systems, and they have limited reach (Glasgow et al., American Journal of Public Health 102:1274-1281, 2012; National Research Council and Institute of Medicine 2009; Prinz and Sanders, Clinical Psychology Review 27:739-749, 2007). To address this challenge and improve public health and well-being at a population level, the Society for Prevention Research (SPR) formed the Mapping Advances in Prevention Science (MAPS) IV Translation Research Task Force, which considered ways to scale up EBIs in five public systems: behavioral health, child welfare, education, juvenile justice, and public health. After reviewing other efforts to scale up EBIs in public systems, a common set of factors were identified as affecting scale-up in all five systems. The most important factor was the degree to which these systems enacted public policies (i.e., statutes, regulations, and guidance) requiring or recommending EBIs and provided public funds for EBIs. Across systems, other facilitators of scale-up were creating EBIs that are ready for scale-up, public awareness of and support for EBIs, community engagement and capacity to implement EBIs, leadership support for EBIs, a skilled workforce capable of delivering EBIs, and data monitoring and evaluation capacity. It was concluded that the following actions are needed to significantly increase EBI scale-up in public systems: (1) provide more public policies and funding to support the creation, testing, and scaling up of EBIs; (2) develop and evaluate specific frameworks that address systems level barriers impeding EBI scale-up; and (3) promote public support for EBIs, community capacity to implement EBIs at scale, and partnerships between community stakeholders, policy makers, practitioners, and scientists within and across systems.

Evaluation of Community-Level Effects of Communities That Care on Adolescent Drug Use and Delinquency Using a Repeated Cross-Sectional Design.

The Communities That Care (CTC) prevention system has shown effects on reducing incidence and prevalence of problem behaviors among a panel of youth followed from 5th through 12th grade. The present report examines whether similar intervention effects could be observed using a repeated cross-sectional design in the same study. Data were from a community-randomized trial of 24 US towns. Cross-sectional samples of sixth, eighth, and tenth graders were surveyed at four waves. Two-stage ANCOVA analyses estimated differences between CTC and control communities in community-level prevalence of problem behaviors for each grade, adjusting for baseline prevalence. No statistically significant reductions in prevalence of problem behaviors were observed at any grade in CTC compared to control communities. Secondary analyses examined intervention effects within a "pseudo cohort" where cross-sectional data were used from sixth graders at baseline and tenth graders 4 years later. When examining effects within the pseudo cohort, CTC compared to control communities showed a significantly slower increase from sixth to tenth grade in lifetime smokeless tobacco use but not for other outcomes. Exploratory analyses showed significantly slower increases in lifetime problem behaviors within the pseudo cohort for CTC communities with high, but not low, prevention program saturation compared to control communities. Although CTC demonstrated effects in a longitudinal panel from the same community-randomized trial, we did not find similar effects on problem behaviors using a repeated cross-sectional design. These differences may be due to a reduced ability to detect effects because of potential cohort effects, accretion of those who were not exposed, and attrition of those who were exposed to CTC programming in the repeated cross-sectional sample.

Effects of Communities That Care on Males' and Females' Drug Use and Delinquency 9 Years After Baseline in a Community-Randomized Trial.

UNLABELLED: This study tested sustained effects of the Communities That Care (CTC) prevention system on health-risking behaviors 9 years after baseline in a community-randomized trial involving 24 towns in seven states. Earlier analyses found sustained effects on abstinence from drug use and delinquency through Grade 12 in a panel of fifth graders. At age 19, 91 % (n = 3986) of the living panel completed the survey. Data were analyzed using generalized linear mixed models. The prevalence of lifetime and current substance use and delinquency were the primary outcomes. Secondary outcomes included substance use disorders, major depression, suicidality, educational attainment, and sexual risk behaviors. CTC had a significant overall effect across lifetime measures of the primary outcomes for males, but not for females or the full sample, although lifetime abstinence from delinquency in the full sample was significantly higher in CTC communities (ARR = 1.16). Males in CTC communities also continued to show greater lifetime abstinence from cigarette smoking (ARR = 1.22). CTC did not have a sustained effect on current substance use and delinquency nor did it improve the secondary outcomes at age 19 for either gender. Communities using CTC may need to extend their prevention planning to include the high school years to sustain effects on drug use and delinquency beyond high school for both genders. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01088542.

Exposure to violence, substance use, and neighborhood context.

Adolescent exposure to violence and substance use are both public health problems, but how neighborhood context contributes to these outcomes is unclear. This study uses prospective data from 1416 adolescents to examine the direct and interacting influences of victimization and neighborhood factors on adolescent substance use. Based on hierarchical Bernoulli regression models that controlled for prior substance use and multiple individual-level factors, exposure to violence significantly increased the likelihood of marijuana use but not alcohol use or binge drinking. There was little evidence that community norms regarding adolescent substance use influenced rates of substance use or moderated the impact of victimization. Community disadvantage did not directly impact substance use, but the relationship between victimization and marijuana use was stronger for those in neighborhoods with greater disadvantage. The results suggest that victimization is particularly likely to affect adolescents' marijuana use, and that this relationship may be contingent upon neighborhood economic conditions.

Benefit-Cost Analysis of a Randomized Evaluation of Communities That Care: Monetizing Intervention Effects on the Initiation of Delinquency and Substance Use Through Grade 12.

OBJECTIVE: To determine whether the Communities That Care (CTC) prevention system is a cost-beneficial intervention. METHODS: Data were from a longitudinal panel of 4,407 youth participating in a randomized controlled trial including 24 towns in 7 states, matched in pairs within state and randomly assigned to condition. Significant differences favoring intervention youth in sustained abstinence from delinquency, alcohol use, and tobacco use through Grade 12 were monetized and compared to economic investment in CTC. RESULTS: CTC was estimated to produce $4,477 in benefits per youth (discounted 2011 dollars). It cost $556 per youth to implement CTC for 5 years. The net present benefit was $3,920. The benefit-cost ratio was $8.22 per dollar invested. The internal rate of return was 21%. Risk that investment would exceed benefits was minimal. Investment was expected to be recouped within 9 years. Sensitivity analyses in which effects were halved yielded positive cost-beneficial results. CONCLUSIONS: CTC is a cost-beneficial, community-based approach to preventing initiation of delinquency, alcohol use, and tobacco use. CTC is estimated to generate economic benefits that exceed implementation costs when disseminated with fidelity in communities.

Avoiding violent victimization among youths in urban neighborhoods: the importance of street efficacy.

OBJECTIVES: We investigated how street efficacy--the perceived ability to avoid dangerous and unsafe situations--is related to violent victimization across different levels of neighborhood disadvantage. METHODS: We used 2 waves of self-report data collected between 1995 and 1999 from 1865 youths in the 9-, 12-, and 15-year-old cohorts of the Project on Human Development in Chicago Neighborhoods to measure violent victimization, street efficacy, and risk factors for violent victimization. We also analyzed data from the 1990 US Census to measure categories of neighborhood concentrated disadvantage for which the cohorts of youths reside. We used logistic regression models to examine the association between street efficacy and violent victimization while we controlled for demographic, family and parenting, self-control, and behavioral and lifestyle variables. RESULTS: Logistic regression results showed that street efficacy had its strongest association with violent victimization in the most disadvantaged neighborhoods (odds ratio = 0.700; 95% confidence interval = 0.55, 0.89). CONCLUSIONS: Our findings support the need to teach youths ways to successfully navigate potentially violent situations in environments that pose moderate to high risks for exposure to violence.

Variation in the sustained effects of the communities that care prevention system on adolescent smoking, delinquency, and violence.

Communities That Care (CTC) is a universal, science-based community prevention system designed to reduce risk, enhance protection, and prevent adolescent health and behavior problems community wide. CTC has been found to have sustained effects on cigarette use and delinquent and violent behaviors in grade 10 in a panel of 4,407 students followed from fifth grade in a community randomized trial. It is important to test variation in the effects of this prevention system designed to be universal to understand for whom it is most effective and whether it fails to produce change or leads to iatrogenic effects for certain categories of individuals. The present study examined variation in the sustained effects of CTC on tenth-grade cigarette use and delinquent and violent behaviors. Interaction analyses suggest that the effect of CTC did not differ between those who had high levels of community-targeted risk factors at baseline or had already engaged in substance use, delinquency, or violence at baseline versus those who had not. Although CTC reduced the prevalence of both girls' and boys' problem behaviors, the effect on delinquency was marginally (p = 0.08) larger for boys than for girls.

The Moderating Effects of Peer and Parental Support on the Relationship Between Vicarious Victimization and Substance Use.

General strain theory (GST) hypothesizes that youth are more likely to engage in delinquency when they experience vicarious victimization, defined as knowing about or witnessing violence perpetrated against others, but that this relationship may be attenuated for those who receive social support from significant others. Based on prospective data from youth aged 8 to 17 participating in the Project on Human Development in Chicago Neighborhoods (PHDCN), this article found mixed support for these hypotheses. Controlling for prior involvement in delinquency, as well as other risk and protective factors, adolescents who reported more vicarious victimization had an increased likelihood of alcohol use in the short term, but not the long term, and victimization was not related to tobacco or marijuana use. Peer support did not moderate the relationship between vicarious victimization and substance use, but family support did. In contrast to strain theory's predictions, the relationship between vicarious victimization and substance use was stronger for those who had higher compared with lower levels of family support. Implications of these findings for strain theory and future research are discussed.

The protective effects of neighborhood collective efficacy on adolescent substance use and violence following exposure to violence.

Research has demonstrated that exposure to violence can result in many negative consequences for youth, but the degree to which neighborhood conditions may foster resiliency among victims is not well understood. This study tests the hypothesis that neighborhood collective efficacy attenuates the relationship between adolescent exposure to violence, substance use, and violence. Data were collected from 1,661 to 1,718 adolescents participating in the Project on Human Development in Chicago Neighborhoods, who were diverse in terms of sex (51% male, 49% female), race/ethnicity (48% Hispanic, 34% African American, 14% Caucasian, and 4% other race/ethnicity), and age (mean age 12 years; range 8-16). Information on neighborhood collective efficacy was obtained from adult residents, and data from the 1990 U.S. Census were used to control for neighborhood disadvantage. Based on hierarchical modeling techniques to adjust for the clustered data, Bernoulli models indicated that more exposure to violence was associated with a greater likelihood of tobacco, alcohol, and marijuana use and perpetration of violence. Poisson models suggested that victimization was also related to a greater variety of substance use and violent behaviors. A moderating effect of collective efficacy was found in models assessing the variety of substance use; the relationship between victimization and substance use was weaker for youth in neighborhoods with higher versus lower levels of collective efficacy. These findings are consistent with literature indicating that social support can ameliorate the negative impact of victimization. This investigation extends this research to show that neighborhood social support can also help to promote resiliency among adolescents.

Worldwide application of prevention science in adolescent health.

The burden of morbidity and mortality from non-communicable disease has risen worldwide and is accelerating in low-income and middle-income countries, whereas the burden from infectious diseases has declined. Since this transition, the prevention of non-communicable disease as well as communicable disease causes of adolescent mortality has risen in importance. Problem behaviours that increase the short-term or long-term likelihood of morbidity and mortality, including alcohol, tobacco, and other drug misuse, mental health problems, unsafe sex, risky and unsafe driving, and violence are largely preventable. In the past 30 years new discoveries have led to prevention science being established as a discipline designed to mitigate these problem behaviours. Longitudinal studies have provided an understanding of risk and protective factors across the life course for many of these problem behaviours. Risks cluster across development to produce early accumulation of risk in childhood and more pervasive risk in adolescence. This understanding has led to the construction of developmentally appropriate prevention policies and programmes that have shown short-term and long-term reductions in these adolescent problem behaviours. We describe the principles of prevention science, provide examples of efficacious preventive interventions, describe challenges and potential solutions to take efficacious prevention policies and programmes to scale, and conclude with recommendations to reduce the burden of adolescent mortality and morbidity worldwide through preventive intervention.

Racial/Ethnic Differences in the Relationship Between Neighborhood Disadvantage and Adolescent Substance Use.

Although social disorganization theory hypothesizes that neighborhood characteristics influence youth delinquency, the impact of neighborhood disadvantage on adolescent substance use and racial/ethnic differences in this relationship have not been widely investigated. The present study examines these issues using longitudinal data from 1,856 African American, Hispanic, and Caucasian adolescents participating in the Project on Human Development in Chicago Neighborhoods (PHDCN). The results indicated that neighborhood disadvantage did not significantly increase the likelihood of substance use for the full sample. When relationships were analyzed by race/ethnicity, one significant (p ≤ .10) effect was found; disadvantage increased alcohol use among African Americans only. The size of this effect differed significantly between African American and Hispanic youth. In no other cases did race/ethnicity moderate the impact of disadvantage on substance use. These results suggest that disadvantage is not a strong predictor of adolescent substance use, although other features of the neighborhood may affect such behaviors.

Gender differences in the effects of exposure to violence on adolescent substance use.

To date, research exploring gender differences in the relationship between exposure to community violence and substance use has been limited. This study employs longitudinal data from the Project on Human Development in Chicago Neighborhoods (PHDCN) to assess the exposure to violence-substance use relationship and explore whether this relationship varies by gender. We find that the two forms of exposure to violence-direct (primary) and indirect (secondary)-independently increase the frequency of subsequent alcohol use, binge drinking, and marijuana use among males and females. One gender difference emerged, as females who had been directly victimized engaged in more frequent binge drinking than males who had been directly victimized. Across both sexes, the effect of each form of violence weakened when other predictors of substance use were included in the models. Future directions for this research are discussed, including policy recommendations to help adolescents cope with victimization experiences.

THE CYCLE OF VIOLENCE IN CONTEXT: EXPLORING THE MODERATING ROLES OF NEIGHBORHOOD DISADVANTAGE AND CULTURAL NORMS.

Although the cycle of violence theory has received empirical support (Widom, 1989a, 1989b), in reality, not all victims of child physical abuse become involved in violence. Therefore, little is known regarding factors that may moderate the relationship between abuse and subsequent violence, particularly contextual circumstances. The current investigation used longitudinal data from 1,372 youth living in 79 neighborhoods who participated in the Project on Human Development in Chicago Neighborhoods (PHDCN), and it employed a multivariate, multilevel Rasch model to explore the degree to which neighborhood disadvantage and cultural norms attenuate or strengthen the abuse-violence relationship. The results indicate that the effect of child physical abuse on violence was weaker in more disadvantaged communities. Neighborhood cultural norms regarding tolerance for youth delinquency and fighting among family and friends did not moderate the child abuse-violence relationship, but each had a direct effect on violence, such that residence in neighborhoods more tolerant of delinquency and fighting increased the propensity for violence. These results suggest that the cycle of violence may be contextualized by neighborhood structural and cultural conditions.

The Impact of the Good Behavior Game on Risk for Drug Use Disorder in an Agent-Based Model of Southern Sweden.

OBJECTIVE: Drug use disorder (DUD) is a worldwide problem, and strategies to reduce its incidence are central to decreasing its burden. This investigation seeks to provide a proof of concept for the ability of agent-based modeling to predict the impact of the introduction of an effective school-based intervention, the Good Behavior Game (GBG), on reducing DUD in Scania, Sweden, primarily through increasing school achievement. METHOD: We modified an existing agent-based simulation model of opioid use disorder to represent DUD in Scania County, southern Sweden. The model represents every individual in the population and is calibrated with the linked individual data from multiple sources including demographics, education, medical care, and criminal history. Risks for developing DUD were estimated from the population in Scania. Scenarios estimated the impact of introducing the GBG in schools located in disadvantaged areas. RESULTS: The model accurately reflected the growth of DUD in Scania over a multiyear period and reproduced the levels of affected individuals in various socioeconomic strata over time. The GBG was estimated to improve school achievement and lower DUD registrations over time in males residing in disadvantaged areas by 10%, reflecting a decrease of 540 cases of DUD. Effects were considerably smaller in females. CONCLUSIONS: This work provides support for the impact of improving school achievement on long-term risks of developing DUD. It also demonstrated the value of using simulation modeling calibrated with data from a real population to estimate the impact of an intervention applied at a population level.

Sustaining the utilization and high quality implementation of tested and effective prevention programs using the communities that care prevention system.

This paper describes the extent to which communities implementing the Communities That Care (CTC) prevention system adopt, replicate with fidelity, and sustain programs shown to be effective in reducing adolescent drug use, delinquency, and other problem behaviors. Data were collected from directors of community-based agencies and coalitions, school principals, service providers, and teachers, all of whom participated in a randomized, controlled evaluation of CTC in 24 communities. The results indicated significantly increased use and sustainability of tested, effective prevention programs in the 12 CTC intervention communities compared to the 12 control communities, during the active phase of the research project when training, technical assistance, and funding were provided to intervention sites, and 2 years following provision of such resources. At both time points, intervention communities also delivered prevention services to a significantly greater number of children and parents. The quality of implementation was high in both conditions, with only one significant difference: CTC sites were significantly more likely than control sites to monitor the quality of implementation during the sustainability phase of the project.

Adverse Childhood Experiences and Adolescent Exposure to Violence.

Adverse childhood experiences (ACEs) are relatively common and can lead to harmful outcomes in adolescence and adulthood. The current study investigates the relationship between ACEs and exposure to violence in adolescence, an important area of research given the high rates of victimization in adolescence and the need for evidence-based strategies to prevent and reduce the negative consequences of victimization. The study also examines sex differences in the effects of ACEs, given that some research finds that the prevalence and impact of ACEs vary for females and males. Research questions were analyzed using prospective data from 766 to 773 high-risk youth and caregivers participating in the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN). A total of 10 ACEs were assessed, including five types of child maltreatment measured using official data from child protective services agencies and five types of household dysfunction reported primarily by caregivers. Exposure to three types of violence (verbal intimidation, physical victimization, and witnessing violence) were measured using youth self-reports. Logistic regression analyses examined the relationship between the number of ACEs experienced before age 12 and the likelihood of violence exposure from ages 15 to 18. Youth experiencing more ACEs had a significantly greater likelihood of physical victimization (with an adjusted odds ratio of 1.15), but not intimidation (Adjusted Odds Ratio [AOR] = 1.10) or witnessing violence (AOR = 1.11). Sex did not significantly moderate these relationships, but in sex-specific analyses, ACEs significantly increased intimidation and victimization for girls and witnessing violence for boys. Although the findings showed inconsistent evidence of a relationship between ACEs and exposure to violence, they support the need for interventions to reduce ACEs and their impact on exposure to violence during adolescence.

The conditioning effects of positive experiences on the ACEs-offending relationship in adolescence.

BACKGROUND: Research shows that adverse childhood experiences (ACEs) are problematic and may impact delinquency and arrest in adolescence. However, resiliency theories suggest the association between ACEs and delinquency/arrest may be mitigated by positive childhood experiences (PCEs). OBJECTIVE: This study tests the hypothesis that an accumulation of PCEs ameliorates the relationship between ACEs and delinquency and arrest during adolescence. PARTICIPANTS AND SETTING: Prospective data were collected from approximately 800 participants in the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN). METHODS: Self-report data from 16-year-old participants were used to measure the two dependent variables: the number of delinquent acts committed and having at least one arrest in the past year. Count measures reflected the number of ACEs and PCEs, with the former based on reports from child protective services, caregivers, and youth collected from ages 4-12, and the latter based on self-reports at age 12. Negative binomial models analyzed delinquency outcomes, logistic regression models examined arrest, and interaction terms assessed moderating effects. RESULTS: ACEs were associated with significantly more delinquent acts but not arrest, and PCEs were associated with significantly fewer delinquent acts but not arrest. PCEs significantly reduced the relationship between ACEs and delinquency but only for youth with moderate levels of ACEs. CONCLUSIONS: Findings indicate a need for additional research measuring the moderating effects of a variety of PCEs and to the need to enhance positive experiences for youth to prevent delinquency.

Effects of Communities That Care on the adoption and implementation fidelity of evidence-based prevention programs in communities: results from a randomized controlled trial.

This paper describes findings from the Community Youth Development Study (CYDS), a randomized controlled trial of the Communities That Care (CTC) prevention system, on the adoption and implementation fidelity of science-based prevention programming in 24 communities. Data were collected using the Community Resource Documentation (CRD), which entailed a multi-tiered sampling process and phone and web-based surveys with directors of community-based agencies and coalitions, school principals, service providers, and teachers. Four years after the initiation of the CTC prevention system, the results indicated increased use of tested, effective prevention programs in the 12 CTC intervention communities compared to the 12 control communities, and significant differences favoring the intervention communities in the numbers of children and families participating in these programs. Few significant differences were found regarding implementation quality; respondents from both intervention and control communities reported high rates of implementation fidelity across the services provided.