Anxiety, depression, and suicidal ideation among early adolescents during the COVID-19 pandemic.

BACKGROUND: Anxiety and depression are among the most common and debilitating psychiatric disorders affecting youth, with both related to increased suicide risk. While rates of youth anxiety and depression were increasing before the COVID-19 pandemic, the pandemic further negatively impacted adolescent mental health. Unfortunately, few studies have examined prevalence of these concerns among early adolescents (ages 10-13) longitudinally during the pandemic. METHOD: The current study examined self-reported anxiety and depression symptoms, and suicidal ideation amongst a general pediatrics population of 11- to 13-year-olds (n = 623) from March through September 2020 (early-pandemic) and approximately 7 months later (September 2020 through May 2021; mid-pandemic). Paired samples proportions were used to examine changes in prevalence of moderate to severe anxiety, depression, and suicidal ideation from early- to mid-pandemic. RESULTS: Results highlight high initial rates and stability in anxiety and suicidal ideation, as well as a significant increase in depression (42.9% increase; p < .05) among the full sample during the COVID-19 pandemic. Prevalance of concerns were greatest for females and Hispanic youth during the early-pandemic, and generally highest for females and Medicaid insured youth at mid-pandemic. DISCUSSION: Results extend recent research and underscore the need for continued monitoring of mental health concerns across development for youth who grew up during the COVID-19 pandemic; highlighting the need for sustainable, effective, and accessible early detection, prevention, and intervention strategies. Improving these services is critical to support youth who experienced pandemic-related stressors, and to prepare for supporting youth during future disruptive and isolating events.

Effect of the Communities That Care Prevention System on Adolescent Handgun Carrying: A Cluster-Randomized Clinical Trial.

Importance: There is little information on upstream community-based interventions that reduce the prevalence of handgun carrying among adolescents, especially those growing up in rural areas. Objective: To test whether Communities That Care (CTC), a community-based prevention system focusing on risk and protective factors for behavioral problems early in life, reduces handgun carrying prevalence among adolescents growing up in rural areas. Design, Setting, and Participants: Community-randomized trial of 24 small towns in 7 states assigned randomly to the CTC or control group with outcomes assessed from 2003 to 2011. Participants were youths attending public schools in grade 5 who received consent from their parents to participate (77% of the eligible population) and were repeatedly surveyed through grade 12 with 92% retention. Analyses were conducted from June to November 2022. Interventions: A coalition of community stakeholders received training and technical assistance to install CTC, used local epidemiologic data to identify elevated risk factors and low protective factors for adolescent behavioral problems, and implemented tested preventive interventions for youth, their families, and schools. Main Outcomes and Measures: Handgun carrying (never vs at least once) operationalized in 2 ways: (1) prevalence of past-year handgun carrying, and (2) cumulative prevalence of handgun carrying from grade 6 through grade 12. Results: Overall, the 4407 study participants' mean (SD) age was 12 (.4) years in both CTC (2405 participants) and control (2002 participants) communities in grade 6; about one-half of participants in each group were female (1220 [50.7 %] in the CTC group and 962 [48.1%] in the control group). From grade 6 through grade 12, 15.5% of participants in CTC communities and 20.7% of those in control communities reported carrying a handgun at least once. Youths in CTC communities were significantly less likely to report handgun carrying at a given grade than those in control communities (odds ratio [OR], 0.73; 95% CI, 0.65-0.82). The most pronounced effects were observed in grade 7 (OR, 0.70; 95% CI, 0.42-0.99), grade 8 (OR, 0.58; 95% CI, 0.41-0.74), and grade 9 (OR, 0.65; 95% CI, 0.39-0.91). Cumulatively from grade 6 through grade 12, youths in CTC communities were significantly less likely to report handgun carrying at least once than those in control communities (OR, 0.76; 95% CI, 0.70-0.84). Overall, CTC reduced the prevalence of past-year handgun carrying by 27% at a given grade and by 24% cumulatively through grade 12. Conclusions and Relevance: In this study, CTC reduced the prevalence of adolescent handgun carrying in participating communities. Trial Registration: ClinicalTrials.gov Identifier: NCT01088542.

School Handgun Carrying Among Youth Growing Up in Rural Communities.

PURPOSE: To characterize school handgun carrying and violence risk factors among rural youth. METHODS: Using a sample of rural youth (n = 1995), we quantified the proportion who carried a handgun to school, carried but not to school, and did not carry across grades 7-12 and endorsed risk factors for violence in individual, peer, school, and community domains. RESULTS: Overall, 3% (95% confidence interval [CI]: 2%-4%) of youth ever carried to school; 15% (95% CI: 14%-16%) carried but not to school; and 82% (95% CI: 80%-84%) never carried. Violence risk factors (e.g., attacking someone) were more commonly endorsed by youth who carried to school (84%; 95% CI: 73%-95%) than those who carried but not to school (51%; 95% CI: 44%-58%) and did not carry (23%; 95% CI: 20%-26%). DISCUSSION: Carrying a handgun to school in rural areas is not common; however, it is associated with risk factors for violence. Understanding violence risk factors among youth who carry handguns to school could inform violence prevention programs in rural areas.

Substance-Specific Risk Factors among Young Adults: Potential Prevention Targets across Cannabis-Permissive Environments.

PURPOSE: This study examined levels of substance-specific risk factors such as perception of harm from substance use among young adults in a range of cannabis-permissive environments. The main objective was to inform future preventive interventions aimed at reducing cannabis use in the context of increasingly permissive environments. METHODS: Data came from the Community Youth Development Study (CYDS) collected in 2016 when participants were about 23 years old (n = 1,722 participants residing in 46 U.S. states). Young adults self-reported their perceptions about the harms related to cannabis, alcohol, and cigarette use; attitudes about and ease of access to cannabis and other substances; and perceived wrongfulness and social acceptability of cannabis, alcohol, and cigarette use and of selling of cannabis and other illegal drugs. RESULTS: Young adults in more permissive cannabis contexts reported higher levels of all cannabis-specific risk factors (e.g., greater access to and more favorable attitudes about cannabis use), except for perception of harm from regular cannabis use. However, permissiveness of the cannabis environment was not associated with heightened levels of risk factors for other substance use (such as alcohol, cigarettes, and opioids). CONCLUSIONS: Future preventive interventions for young adults living in more permissive cannabis contexts may need to focus on cannabis-specific risk factors in particular and go beyond considerations of harm from regular use. Future studies should replicate these findings with other samples.

Trajectories of Handgun Carrying in Rural Communities From Early Adolescence to Young Adulthood.

Importance: Characterizing patterns of handgun carrying among adolescents and young adults can inform programs to reduce firearm-related harm. Longitudinal patterns of handgun carrying among rural adolescents have not been identified. Objectives: To assess specific points of intervention by characterizing patterns of handgun carrying by youths in rural communities from early adolescence to young adulthood and to quantify how age at initiation, duration, and frequency of carrying differ across identified patterns. Design, Setting, and Participants: This cohort study uses the control group of the community-randomized trial of the Communities That Care prevention system, conducted among public school students in 12 rural communities across 7 states. Participants self-reported their handgun carrying at 10 data collection points from 12 to 26 years of age (2005-2019). Data were analyzed from January to July 2021. Main Outcomes and Measures: Handgun carrying in the past 12 months. Latent class growth analysis was used to estimate handgun carrying trajectories. Results: In this longitudinal rural sample of 2002 students, 1040 (51.9%) were male; 532 (26.6%) were Hispanic, Latino, Latina, or Latinx; 1310 (65.4%) were White; and the highest level of educational attainment of either parent was a high school degree or less for 649 students (32.4%). The prevalence of handgun carrying in the last 12 months ranged from 5.3% (95 of 1795) to 7.4% (146 of 1969) in adolescence and increased during the mid-20s (range, 8.9% [154 of 1722] to 10.9% [185 of 1704] from 23 to 26 years of age). Among the participants who reported handgun carrying at least once between 12 and 26 years of age (n = 601 [30.0%]), 320 (53.2%) reported carrying a handgun in only 1 wave. Latent class growth analysis indicated 6 longitudinal trajectories: never or low probability of carrying (1590 [79.4%]), emerging adulthood carrying (166 [8.3%]), steadily increasing carrying (163 [8.1%]), adolescent carrying (53 [2.6%]), declining carrying (24 [1.2%]), and high probability and persistent carrying (6 [0.3%]). The earliest mean (SD) age at initiation of handgun carrying occurred in both the adolescent and declining carrying groups at the ages of 12.6 (0.9) and 12.5 (0.7) years, respectively. More than 20% of some groups (emerging adulthood [age 26 years: 49 of 154 (31.8%)], steadily increasing [age 26 years: 37 of 131 (28.2%)], declining [age 13 years: 7 of 23 (30.4%)], and high probability and persistent carrying [age 15 years: 3 of 6 (50.0%)]) reported carrying 40 times or more in the past year by the age of 26 years. Conclusions and Relevance: This study found distinct patterns of handgun carrying from adolescence to young adulthood in rural settings. Findings suggest that promoting handgun safety in rural areas should start early. Potential high-risk trajectories, including carrying at high frequencies, should be the focus of future work to explore the antecedents and consequences of handgun carrying in rural areas.

Adaptation of the Communities That Care Youth Survey for use in Brazil: A pilot study.

Substance use and violence are serious problems affecting Brazilian youth, prompting local authorities to invest in adapting and implementing evidence-based prevention programs developed abroad. To ensure that interventions are effective, valid and reliable measures of risk factors for substance use and violence are needed. We conducted a pilot examination of the measurement properties of risk factors in the Communities That Care Youth Survey (CTCYS), a school-based survey developed in the United States. The Brazilian-adapted CTCYS included 25 risk factors as well as measures of substance use and antisocial behaviors. The survey was translated into Brazilian Portuguese and adapted for use in Brazil, incorporating suggestions from local experts. The survey was administered to 926 students in one Brazilian community. Results indicate that scale internal consistency was acceptable for all but two scales: (i) Academic Failure and (ii) Rebelliousness. Confirmatory factor analyses suggested good model fit for most measurement models albeit with minor modifications for most scales. Findings from this pilot study provide a foundation for the use of the CTCYS in Brazil to assess community levels of adolescent risk and evaluate prevention programs.

Long-term Impacts and Benefit-Cost Analysis of the Communities That Care Prevention System at Age 23, 12 Years After Baseline.

This study estimated sustained impacts and long-term benefits and costs of the Communities That Care (CTC) prevention system, implemented and evaluated in a longitudinal cluster-randomized trial involving 24 communities in seven states. Analyses utilized reports from a longitudinal panel of 4407 participants, followed since the study's baseline in grade 5, with most recent follow-up 12 years later at age 23. Impacts on lifetime abstinence from primary outcomes of substance use and antisocial behavior were estimated using generalized linear mixed Poisson regression analysis, adjusted for individual and community-level covariates. Possible cascading effects on 4-year college completion, major depressive disorder, and generalized anxiety disorder through age 23 were evaluated as secondary outcomes. CTC had a statistically significant global effect on primary outcomes and also on combined primary and secondary outcomes. Among primary outcomes, point estimates suggested absolute improvements in lifetime abstinence of 3.5 to 6.1% in the intervention arm and relative improvements of 13 to 55%; 95% confidence intervals revealed some uncertainty in estimates. Among secondary outcomes, 4-year college completion was 1.9% greater among young adults from intervention communities, a 20% relative improvement. Mental health outcomes were approximately the same across trial arms. Although CTC had small sustained effects through age 23, benefit-cost analyses indicated CTC was reliably cost beneficial, with a net present value of $7152 (95% credible interval: $1253 to $15,268) per participant from primary impacts and $17,919 ($306 to $39,186) when secondary impacts were also included. It remained cost beneficial even when impacts were adjusted downward due to the involvement of CTC's developer in the trial. Findings suggest that broader dissemination of CTC could improve public health and individual lives in the long term and generate positive net benefits to society.

A Comparison of Cut Points for Measuring Risk Factors for Adolescent Substance Use and Antisocial Behaviors in the U.S. and Colombia.

As the identification and targeting of salient risk factors for adolescent substance use become more widely used globally, an essential question arises as to whether U.S.-based cut points in the distributions of these risk factors that identify "high" risk can be used validly in other countries as well. This study examined proportions of youth at "high" risk using different empirically derived cut points in the distributions of 18 measured risk factors. Data were obtained from large-scale samples of adolescents in Colombia and the United States. Results indicated that significant (p < 0.05) differences in the proportions of "high" risk youth were found in 38.9% of risk factors for 6th graders, 61.1% for 8th graders, and 66.6% for 10th graders. Colombian-based cut points for determining the proportion of Colombian youth at "high" risk were preferable to U.S.-based cut points in almost all comparisons that exhibited a significant difference. Our findings suggest that observed differences were related to the type of risk factor (e.g., drug specific vs. non-drug specific). Findings from this study demonstrate the need for collecting large-scale national data on risk factors for adolescent substance use and developing country-specific cut points based on the distributions of these measures to avoid misidentification of youth at "high" risk.

Testing the Question-Behavior Effect of Self-Administered Surveys Measuring Youth Drug Use.

PURPOSE: Concern that asking about a specific behavior could elicit that behavior is often cited as a reason that communities and schools should not administer surveys about youth drug use. In this study, we investigated if this question-behavior effect exists related to substance use. We examined if simply asking a student about their current drug use leads to an increase in drug use 1 year later. METHOD: This study tests the validity of the question-behavior effect on youth drug use in a longitudinal panel of 2,002 elementary school students. The sample of students was drawn from the Community Youth Development Study, a community-randomized test of the Communities That Care prevention system. If the prevalence of self-reported drug use in sixth grade in a sample surveyed in fifth and sixth grades was higher than in an accretion sample surveyed only in sixth grade, the difference could indicate a question-behavior effect. RESULTS: Results from logistic regression analyses did not provide any evidence of a question-behavior effect on 30-day or lifetime prevalence of alcohol, tobacco, inhalant, or marijuana use reported in sixth grade. CONCLUSIONS: Asking youth about drug use in a survey did not increase the rates of self-reported drug use measured 1 year later. The absence of evidence of a question-behavior effect should ease concerns of communities and schools when administering surveys asking youth about their drug use.

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.

Examination of Substance Use, Risk Factors, and Protective Factors on Student Academic Test Score Performance.

BACKGROUND: School administrators and teachers face difficult decisions about how best to use school resources to meet academic achievement goals. Many are hesitant to adopt prevention curricula that are not focused directly on academic achievement. Yet, some have hypothesized that prevention curricula can remove barriers to learning and, thus, promote achievement. We examined relationships among school levels of student substance use and risk and protective factors that predict adolescent problem behaviors and achievement test performance. METHODS: Hierarchical generalized linear models were used to predict associations involving school-averaged levels of substance use and risk and protective factors and students' likelihood of meeting achievement test standards on the Washington Assessment of Student Learning, statistically controlling for demographic and economic factors known to be associated with achievement. RESULTS: Levels of substance use and risk/protective factors predicted the academic test score performance of students. Many of these effects remained significant even after controlling for model covariates. CONCLUSIONS: Implementing prevention programs that target empirically identified risk and protective factors has the potential to have a favorable effect on students' academic achievement.

Prevention system mediation of communities that care effects on youth outcomes.

This study examined whether the significant intervention effects of the Communities That Care (CTC) prevention system on youth problem behaviors observed in a panel of eighth-grade students (Hawkins et al. Archives of Pediatrics and Adolescent Medicine 163:789-798 2009) were mediated by community-level prevention system constructs posited in the CTC theory of change. Potential prevention system constructs included the community's degree of (a) adoption of a science-based approach to prevention, (b) collaboration on prevention activities, (c) support for prevention, and (d) norms against adolescent drug use as reported by key community leaders in 24 communities. Higher levels of community adoption of a science-based approach to prevention and support for prevention in 2004 predicted significantly lower levels of youth problem behaviors in 2007, and higher levels of community norms against adolescent drug use predicted lower levels of youth drug use in 2007. Effects of the CTC intervention on youth problem behaviors by the end of eighth grade were mediated fully by community adoption of a science-based approach to prevention. No other significant mediated effects were found. Results support CTC's theory of change that encourages communities to adopt a science-based approach to prevention as a primary mechanism for improving youth outcomes.

Sustained effects of the Communities That Care system on prevention service system transformation.

OBJECTIVES: We examined whether the Communities That Care (CTC) system sustained effects 1.5 years after study funding ended on prevention system constructs expected to be important for community-level reductions in drug use and antisocial behaviors among youths. METHODS: Data were from a community trial of 24 towns in the United States randomized to either the CTC intervention or control conditions. Participants were 928 community key leaders interviewed at 1 to 4 waves from 2001 to 2009. Intervention activities, including training and technical assistance, were conducted between 2003 and 2008 in the CTC communities. RESULTS: Leaders from CTC communities reported higher levels of adoption of a science-based approach to prevention and a higher percentage of funding desired for prevention activities in 2009 than did leaders in control communities. CTC communities showed a higher increase over time in community norms against adolescent drug use as well as adoption of a science-based approach compared with control communities. CONCLUSIONS: These findings indicated that CTC implementation produced enduring transformation of important prevention system constructs in intervention communities, which might, in turn, produce long-term reductions in youth problem behaviors.

Predictive validity of established cut points for risk and protective factor scales from the communities that care youth survey.

Community coalitions are a popular strategy to coordinate activities and resources to prevent adolescent substance use and delinquent behavior. Despite early evidence of their lack of effectiveness, a new generation of community coalitions has shown positive results in preventing youth substance use and delinquency. This success can be attributed to coalition decision making focused on reducing local risk factors and increasing local protective factors through the use of evidence-based prevention programs. A previous study using cross-sectional data established cut point values for scales measuring risk and protective factors on the Communities That Care Youth Survey (CTCYS) to identify high levels of risk and low levels of protection in communities on each scale. The current study extended this previous research by using longitudinal data to assess the validity of risk and protective factor cut point values in predicting substance use and delinquent behavior 1 year after risk and protection were measured. The findings demonstrate the predictive validity of cut points for risk and protective factor scales measured by the CTCYS and suggest their utility in guiding prevention efforts.

Cost-benefit analysis of communities that care outcomes at eighth grade.

This paper presents a cost-benefit analysis of the Communities That Care (CTC) prevention system, a public health approach to reducing risk, enhancing protection, and reducing the prevalence of adolescent health and behavior problems community wide. The analysis is based on outcomes from a panel of students followed from Grade 5 through Grade 8 in a randomized controlled trial involving 24 communities in 7 states. Previous analyses have shown that CTC prevented the initiation of cigarette smoking, alcohol use, and delinquency by the end of 8th grade in CTC communities compared to controls. This paper estimates long-term monetary benefits associated with significant intervention effects on cigarette smoking and delinquency as compared to the cost of conducting the intervention. Under conservative cost assumptions, the net present benefit is $5,250 per youth, including $812 from the prevention of cigarette smoking and $4,438 from the prevention of delinquency. The benefit-cost ratio indicates a return of $5.30 per $1.00 invested. Under less conservative but still viable cost assumptions, the benefit-cost ratio due to prevention of cigarette smoking and delinquency increases to $10.23 per $1.00 invested. Benefits from CTC's reduction in alcohol initiation as well as broader inclusion of quality-of-life gains would further increase CTC's benefit-cost ratio. Results provide evidence that CTC is a cost-beneficial preventive intervention and a good investment of public dollars, even under very conservative cost and benefit assumptions.

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.

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.

Prevention Service System Transformation Using Communities That Care.

This study examines prevention system transformation as part of a community-randomized controlled trial of Communities That Care (CTC). Using data from surveys of community leaders, we examine differences between CTC and control communities 4.5 years after CTC implementation. Significantly higher levels of adopting a science-based approach to prevention observed in CTC communities compared to controls in 2004 were maintained in 2007. Leaders in CTC communities expressed a willingness to contribute significantly more funds to prevention than did leaders in control communities in 2007. Significant differences in levels of community collaboration observed in 2004 were not maintained in 2007. Leaders in CTC communities with high poverty rates and large minority student populations reported higher levels of community norms against drug use and greater use of the social development strategy, respectively, than did leaders in control communities with similar characteristics.

Implementation of the Communities That Care Prevention System by Coalitions in the Community Youth Development Study.

While advances in prevention science over the past 2 decades have produced a growing list of tested and effective programs and policies for preventing adolescent delinquency and drug use, widespread dissemination and high-quality implementation of effective programs and policies in communities has not been achieved. The Community Youth Development Study (CYDS) is a randomized, community-level trial of the Communities That Care (CTC) system for promoting science-based prevention in communities. This paper compares 12 community prevention coalitions implementing the CTC system in 12 intervention communities as part of the CYDS to prevention coalitions located in the 12 control communities. As hypothesized, the CYDS coalitions implemented significantly more of the CTC core intervention elements, and also implemented significantly greater numbers of tested, effective prevention programs than the prevention coalitions in the control communities. Implications of the findings for efforts to achieve widespread dissemination of effective prevention programs, policies, and practices are discussed.

Design and analysis of the Community Youth Development Study longitudinal cohort sample.

Communities That Care (CTC) is a prevention system designed to reduce adolescent substance use and delinquency through the selection of effective preventive interventions tailored to a community's specific profile of risk and protection. A community-randomized trial of CTC, the Community Youth Development Study, is currently being conducted in 24 communities across the United States. This article describes the rationale, multilevel analyses, and baseline comparability for the study's longitudinal cohort design. The cohort sample consists of 4,407 fifth- and sixth-grade students recruited in 2004 and 2005 and surveyed annually through ninth grade. Results of mixed-model ANOVAs indicated that students in CTC and control communities exhibited no significant differences (ps > .05) in baseline levels of student outcomes.