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.

Racial Differences in Mechanisms Linking Childhood Socioeconomic Status With Growth in Adult Body Mass Index: The Role of Adolescent Risk and Educational Attainment.

PURPOSE: The present study examined whether risk factors during adolescence, including substance use, depression, overweight status, and young adult educational attainment, mediated the association between low childhood socioeconomic status (SES) and higher body mass index (BMI) in adulthood. We also evaluated whether the hypothesized pathways differed based on racial group status. METHODS: Participants from the Seattle Social Development Project were followed from ages 10 to 39years. Thepresent study included white (n = 381), African American (n = 207), and Asian American (n = 171) participants. Structural equation models tested pathways linking low childhood SES to BMI from ages 24 to 39 years. Multiple-group modeling was used to test potential racial differences. RESULTS: Analyses indicated racial differences in the pathways linking low childhood SES with adult BMI. For whites, overweight status and educational attainment were significant mediators. For Asian Americans, there was an unmediated and significant pathway between low childhood SES and low adult BMI. For African Americans, there were no significant mediated or unmediated pathways. CONCLUSIONS: Results stress that the pathways that link childhood SES with adult BMI may operate differently based on race. Research is particularly needed to identify mechanisms for African Americans in order to better inform obesity prevention efforts.

Effects of Exposure to the Communities That Care Prevention System on Youth Problem Behaviors in a Community-Randomized Trial: Employing an Inverse Probability Weighting Approach.

Earlier intention-to-treat (ITT) findings from a community-randomized trial demonstrated effects of the Communities That Care (CTC) prevention system on reducing problem behaviors among youth. In ITT analyses, youth were analyzed according to their original study community's randomized condition even if they moved away from the community over the course of follow-up and received little to no exposure to intervention activities. Using inverse probability weights (IPWs), this study estimated effects of CTC in the same randomized trial among youth who remained in their original study communities throughout follow-up. Data were from the Community Youth Development Study, a community-randomized trial of 24 small towns in the United States. A cohort of 4,407 youth was followed from fifth grade (prior to CTC implementation) to eighth grade. IPWs for one's own moving status were calculated using fifth- and sixth-grade covariates. Results from inverse probability weighted multilevel models indicated larger effects for youth who remained in their study community for the first 2 years of CTC intervention implementation compared to ITT estimates. These effects included reduced likelihood of alcohol use, binge drinking, smokeless tobacco use, and delinquent behavior. These findings strengthen support for CTC as an efficacious system for preventing youth problem behaviors.

Neighborhood, Family, and Peer Factors Associated with Early Adolescent Smoking and Alcohol Use.

There is broad agreement that neighborhood contexts are important for adolescent development, but there is less consensus about their association with adolescent smoking and alcohol use. Few studies have examined associations between neighborhood socioeconomic contexts and smoking and alcohol use while also accounting for differences in family and peer risk factors for substance use. Data drawn from the Seattle Social Development Project (N = 808), a gender-balanced (female = 49%), multiethnic, theory-driven longitudinal study originating in Seattle, WA, were used to estimate trajectories of smoking and alcohol use from 5th to 9th grade. Time-varying measures of neighborhood socioeconomic, family, and peer factors were associated with smoking and alcohol use at each wave after accounting for average growth in smoking and alcohol use over time and demographic differences. Results indicated that living in more socioeconomically disadvantaged neighborhoods, lower family income, lower family general functioning, more permissive family smoking environments, and affiliation with deviant peers were independently associated with increased smoking. Lower family functioning, more permissive family alcohol use environments, and deviant peers were independently associated with increased alcohol use. The effect of neighborhood disadvantage on smoking was mediated by family income and deviant peers while the effect of neighborhood disadvantage on alcohol use was mediated by deviant peers alone. Family functioning and family substance use did not mediate associations between neighborhood disadvantage and smoking or alcohol use. The results highlight the importance of neighborhood, family, and peer factors in early adolescent smoking and alcohol use. Future studies should examine the unique association of neighborhood disadvantage with adolescent smoking net of family socioeconomics, functioning, and substance use, as well as peer affiliations. Better understanding of the role of contextual factors in early adolescent smoking and alcohol use can help bolster efforts to prevent both short and long harms from substance use.

Assessment of Risk and Protection in Native American Youth: Steps Toward Conducting Culturally Relevant, Sustainable Prevention in Indian Country.

Background: This study constitutes a building block in the cultural adaptation of Communities That Care (CTC), a community-based prevention system that has been found to be effective in reducing youth problem behaviors. Methods: Using the data from the CTC normative survey dataset that consists of more than quarter million youth nationwide, this study examines the reliability and validity of scores derived from the Communities That Care Youth Survey (CTC-YS), one of the primary assessment tools for gathering community data on risk and protective factors related to problem behaviors including substance use. The reliability and criterion validity analyses are conducted overall for the nationwide sample of youth as well as for the student subsample of Native American youth. Results: The results of this study indicate that the existing CTC-YS assessments of risk and protective factors in the domains of community, family, school, and peer groups as well as within individuals yield scores that are reliable and valid within the Native American sample of youth. Conclusions: This study informs the third step in the CTC prevention planning process, which involves the assessment of risk and protective factors to be targeted in preventive interventions. The question of how the assessment of risk and protective factors among Native American youth might be further improved and a description of efforts related to the cultural adaptation of the CTC program currently underway are also addressed in the discussion.

Primary Health Care: Potential Home for Family-Focused Preventive Interventions.

Family-focused prevention programs have been shown to effectively reduce a range of negative behavioral health outcomes but have had limited reach. Three key barriers must be overcome to expand the reach of family-focused prevention programs and thereby achieve a significant public health impact. These barriers are (1) current social norms and perceptions of parenting programs; (2) concerns about the expertise and legitimacy of sponsoring organizations to offer parenting advice; and (3) a paucity of stable, sustainable funding mechanisms. Primary healthcare settings are well positioned to overcome these barriers. Recent changes within health care make primary care settings an increasingly favorable home for family-focused prevention and suggest possibilities for sustainable funding of family-focused prevention programs. This paper discusses the existing advantages of primary care settings and lays out a plan to move toward realizing the potential public health impact of family-focused prevention through widespread implementation in primary healthcare settings.

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.

Long-term consequences of adolescent gang membership for adult functioning.

OBJECTIVES: We examined the possible public health consequences of adolescent gang membership for adult functioning. METHODS: Data were drawn from the Seattle Social Development Project, a longitudinal study focusing on the development of positive and problem outcomes. Using propensity score matching and logistic regression analyses, we assessed the effects of adolescent gang membership on illegal behavior, educational and occupational attainment, and physical and mental health at the ages of 27, 30, and 33 years. RESULTS: In comparison with their nongang peers, who had been matched on 23 confounding risk variables known to be related to selection into gang membership, those who had joined a gang in adolescence had poorer outcomes in multiple areas of adult functioning, including higher rates of self-reported crime, receipt of illegal income, incarceration, drug abuse or dependence, poor general health, and welfare receipt and lower rates of high school graduation. CONCLUSIONS: The finding that adolescent gang membership has significant consequences in adulthood beyond criminal behavior indicates the public health importance of the development of effective gang prevention programs.

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.

How has the economic downturn affected communities and implementation of science-based prevention in the randomized trial of communities that care?

This study examined implications of the economic downturn that began in December 2007 for the Community Youth Development Study (CYDS), a longitudinal randomized controlled trial of the Communities That Care (CTC) prevention system. The downturn had the potential to affect the internal validity of the CYDS research design and implementation of science-based prevention in study communities. We used archival economic indicators and community key leader reports of economic conditions to assess the extent of the economic downturn in CYDS communities and potential internal validity threats. We also examined whether stronger economic downturn effects were associated with a decline in science-based prevention implementation. Economic indicators suggested the downturn affected CYDS communities to different degrees. We found no evidence of systematic differences in downturn effects in CTC compared to control communities that would threaten internal validity of the randomized trial. The Community Economic Problems scale was a reliable measure of community economic conditions, and it showed criterion validity in relation to several objective economic indicators. CTC coalitions continued to implement science-based prevention to a significantly greater degree than control coalitions 2 years after the downturn began. However, CTC implementation levels declined to some extent as unemployment, the percentage of students qualifying for free lunch, and community economic problems worsened. Control coalition implementation levels were not related to economic conditions before or after the downturn, but mean implementation levels of science-based prevention were also relatively low in both periods.

The application of meta-analysis within a matched-pair randomized control trial: an illustration testing the effects of communities that care on delinquent behavior.

Use of meta-analytic strategies to test intervention effects is an important complement to traditional design-based analyses of intervention effects in randomized control trials. In the present paper, we suggest that meta-analyses within the context of matched-pair designs can provide useful insight into intervention effects. We illustrate the advantages to this analytic strategy by examining the effectiveness of the Communities That Care (CTC) prevention system on 8th-grade delinquent behavior in a randomized matched-pair trial. We estimate the intervention effect within each of the matched-pair communities, aggregate the effect sizes across matched pairs to derive an overall intervention effect, and test for heterogeneity in the effect of CTC on delinquency across matched pairs of communities. The meta-analysis finds that CTC reduces delinquent behavior and that the effect of CTC on delinquent behavior varies significantly across communities. The use of meta-analysis in randomized matched-pair studies can provide a useful accompaniment to other analytic approaches because it opens the possibility of identifying factors associated with differential effects across units or matched pairs in the context of a randomized control trial.

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.

The role of maternal early-life and later-life risk factors on offspring low birth weight: findings from a three-generational study.

PURPOSE: This study examined three research questions: (1) Is there an association between maternal early-life economic disadvantage and the birth weight of later-born offspring? (2) Is there an association between maternal abuse in childhood and the birth weight of later-born offspring? (3) To what extent are these early-life risks mediated through adolescent and adult substance use, mental and physical health status, and adult socioeconomic status (SES)? METHODS: Analyses used structural equation modeling to examine data from two longitudinal studies, which included three generations. The first generation (G1) and the second generation (G2) were enrolled in the Seattle Social Development Project (SSDP), and the third generation (G3) was enrolled in the SSDP Intergenerational Project. Data for the study (N = 136) focused on (G2) mothers enrolled in the SSDP and their children (G3). RESULTS: Analyses revealed that G2 low childhood SES predicted G3 offspring birth weight. Early childhood abuse among G2 respondents predicted G3 offspring birth weight through a mediated pathway including G2 adolescent substance use and G2 prenatal substance use. Birth weight was unrelated to maternal adult SES, depression, or obesity. CONCLUSIONS: To our knowledge, this is the first study to identify the effect of maternal early-life risks of low childhood SES and child maltreatment on later-born offspring birth weight. These findings have far-reaching effects on the cumulative risk associated with early-life economic disadvantage and childhood maltreatment. Such findings encourage policies and interventions that enhance child health at birth by taking the mother's own early-life and development into account.

Growth in adolescent delinquency and alcohol use in relation to young adult crime, alcohol use disorders, and risky sex: a comparison of youth from low- versus middle-income backgrounds.

BACKGROUND: This study examined adolescent delinquency and alcohol use in relation to young adult crime, alcohol use disorders (AUDs), and risky sex. Analyses further examined the influences of late childhood involvement in these problem behavior outcomes, with mediation through teen delinquency and alcohol use, and examined differences in the pathways for youth from low- compared to middle-income backgrounds. METHOD: Multiple-group latent growth curve modeling was conducted using data collected from a sample of 808 youth followed from age 10 to age 24. Self-report assessments included delinquent involvement, alcohol use, and sexual activity in late childhood; delinquency and alcohol use in adolescence; and crime, AUDs, and risky sex in early adulthood. RESULTS: Late childhood delinquent involvement was associated with young adult crime, AUDs, and risky sex indirectly through adolescent delinquency, and had a persistent direct effect on crime. Adolescent delinquency also mediated the relation between early sex onset and crime. Early alcohol use predicted a higher level of, and a faster rate of increase in, adolescent drinking, which predicted, in turn, young adult AUDs and risky sex. Significant group differences indicated stronger associations between adolescent delinquency and each young adult outcome for youth from low- compared to those from middle-income backgrounds. CONCLUSIONS: Early intervention may help prevent the development of crime, AUDs, and risky sex behaviors, especially among disadvantaged youth.

Assessment of Behavior Problems in Childhood and Adolescence as Predictors of Early Adult Depression.

Behavior and psychological problems assessed prospectively by teachers and parents and by youths' self-reports through late childhood and adolescence were examined as possible predictors of early adult depression. Data were from 765 participants in the Seattle Social Development Project, a multiethnic and gender-balanced urban sample. Analyses examined 7 waves of data from ages 10 to 21, and included measures from the Achenbach Child Behavior Checklist and assessments of past-year depressive episode based on the Diagnostic Interview Schedule. Self-reported conduct problems as early as age 10 (Mason et al., 2001) and throughout adolescence consistently predicted depression at age 21. Parent reports of conduct and other externalizing problems in adolescence also significantly predicted adult depression. None of the available teacher reports through age 14 were significant predictors. Results suggest that externalizing problems can be useful indicators of risk for adult depression. Prevention efforts that target externalizing problems in youth may hold promise for reducing later depression.

Bridging science to practice: achieving prevention program implementation fidelity in the community youth development study.

This paper describes the development, application, and results of an implementation monitoring component of the Communities That Care (CTC) prevention framework used in the Community Youth Development Study (CYDS) to ensure high-fidelity prevention program implementation. This system was created based on research that community-based implementation of evidence-based prevention programs often includes adaptations in program design, content, or manner of delivery (Gottfredson and Gottfredson, Journal of research in crime and delinquency, 39, 3-35, 2002; Hallfors and Godette, Health Education Research, 17, 461-470, 2002; Wandersman and Florin, American Psychologist, 58, 441-448, 2003). A lack of fidelity to the implementation standards delineated by program designers is one indicator of a gap between prevention science and practice which can lessen the likelihood that communities will realize the positive participant effects demonstrated in research trials. By using the CTC model to select and monitor the quality of prevention activities, the 12 CYDS communities replicated 13 prevention programs with high rates of adherence to the programs' core components and in accordance with dosage requirements regarding the number, length, and frequency of sessions. This success indicates the potential of the CTC program implementation monitoring system to enhance community Prevention Delivery Systems (Wandersman et al. American Journal of Community Psychology, this issue) and improve the likelihood of desired participant changes.

Youth violence trajectories and proximal characteristics of intimate partner violence.

Analyses first examined the developmental course of intimate partner violence (IPV), beginning with trajectories of youth violence. We then examined potential mediators of prior youth violence trajectories in models predicting later IPV perpetration as an outcome. Potential mediators include risks associated with the individual (e.g., current alcohol and drug use and mental health diagnosis), characteristics of a perpetrator's partner (e.g., use of alcohol/drugs and history of antisocial behavior), and aspects of the surrounding community (e.g., neighborhood norms favorable to violence and drug use). Data are from the Seattle Social Development Project, a longitudinal study of over 800 individuals followed from elementary school to young adulthood (age 24). Findings suggest that both chronic and late-increaser patterns of youth violence elevated the likelihood of later IPV perpetration. Partial mediation effects of the relation between youth violence and IPV were found for variables related to one's partner and the surrounding community. Individual characteristics of the perpetrator were not uniquely predictive of IPV when measured as a risk index and modeled along with other risk factors. Findings indicate that the risk of IPV could be lessened by addressing earlier forms of violence and by intervening to reduce risks within and across domains of influence.

Family influences on the risk of daily smoking initiation.

PURPOSE: To examine developmental patterns and family influences on the risk of daily smoking initiation from adolescence to young adulthood. METHOD: A gender-balanced, ethnically diverse urban sample of 808 children aged 10-11 years was surveyed in 1985 and followed prospectively to age 21 in 1996. Discrete-time survival analysis was used to assess the hazard of initiation of daily smoking during this time period, as well as the effects of family factors on the risk of daily smoking initiation. RESULTS: Less parental smoking, more strict family monitoring and rules, and stronger family bonding predicted a significantly lower risk of daily smoking initiation controlling for socio-demographic background. The decline in the impact of family bonding over time was marginally significant; however, none of the interactions between family factors and time were significant, indicating generally consistent family influences on daily smoking from age 10 to 21. CONCLUSIONS: The present findings indicate that parent smoking contributes to the onset of daily smoking in their teenagers even if parents practice good family management, hold norms against teen tobacco use, and do not involve their children in their own tobacco use. Smoking prevention programs should include components focused on parents of adolescents. To reduce risks for daily smoking among adolescents, it is important to encourage parents to stop or reduce their own smoking. In addition, these data indicate that parents can reduce their children's risk of daily smoking initiation by reducing family conflict, by maintaining strong bonds with their children, by setting clear rules, and by closely monitoring their children's behaviors.

Community variation in risk and protective factors and substance use outcomes.

Communities are the context in which many prevention activities take place. One approach to community prevention is to identify the most elevated risk factors and most depressed protective factors for substance use in a community and then to select and implement preventive interventions to address the most elevated risk factors and most depressed protective factors in the community. This approach presumes that there are reliable differences between communities in risk and protection and that these differences relate to differences in substance use across communities. This paper addresses these issues using data from 28,091 students in 41 communities across the U.S. Intraclass correlation coefficients are used to assess the degree to which there are reliable and meaningful differences between communities in levels of risk and protective factors. The community means of the risk and protective factors are then correlated with levels of substance use. Findings indicate that there are meaningful differences between communities in levels of specific risk and protective factors, and that those differences are related to different levels of substance use in these communities. These results provide an empirical foundation for tailoring community-wide efforts to prevent substance abuse to the specific profiles of risk and protective factors experienced by youths in different communities.