week 9: Prevention of addictive substance use

Question 1

Define the following key terms: prevention science, and risk process theories, and their theoretical inter-relationships relevant to the prevention of addiction

Answer 1

Prevention science is a field that integrates knowledge from a range of disciplines to increase the effectiveness and dissemination of prevention efforts. The prevention science field synthesises knowledge from: life course development research; community epidemiology; the evaluation of preventive intervention trials; and service system approaches. Prevention science approaches direct evidence-based investment to modify the early developmental pathways and influences that lead to problems such as addictions

Risk process theories seek to explain why some people emerge from their life journey with an increased risk of addiction. We can think of life course development as the study of human growth through different ages and stages.

Physical and cognitive-neurological development problems

• These can occur when children and young people experience stressful and traumatic negative experiences (such as child maltreatment and peer bullying) that are maintained over time. The extended arousal of the nervous system and the release of stress hormones such as cortisol can result in permanent damage to the development of the brain, and stress and immunity systems. Stresses in an individual’s life can begin in-utero. Because the development of biological stress response systems is influenced by early experience, early exposure to severe stress can “biologically embed” lifetime vulnerabilities in stress response systems that increase adverse outcomes such as addictions. Early exposure to severe stress is thus a risk factor for physical, emotional and cognitive problems that can increase the risk of addictions.
• As the early years set the foundations for healthy physical development, exposure to substances in the early years can “embed” problems in the developmental sequence and result in more severe problems later life. Some risk factors such as maternal and adolescent alcohol use are common causes of physical changes such as tolerance to alcohol that increase the likelihood of adult substance abuse and related outcomes for large numbers across the population.
• Genetic factors are an additional biological factor that can increase the risk of addiction. Although genetic pathways are understood to increase risk, to date they have not been targeted to prevent addictions.

Behavioural development theories

-Behavioural development theories of addiction refer to the tendency for the early introduction of substance use behaviours to shape the later sequence of behavioural development that can lead to addictions. For example, being exposed to tobacco use in childhood and using cigarettes in early adolescence increase the likelihood of becoming addicted to substances in adulthood. Underlying the development of addictive behaviours are physical and neurological changes that result in the learning of habits that are then established in social identify and lifestyles.

Social development theories

-refer to the tendency for the development of behaviour to be influenced by positive social bonding and role modelling. Early socialisation occurs in the family then progresses later in childhood at school and with peers. In later stages, adolescent and youth socialisation is influenced by the wider community norms. As two examples, the risk of illicit drug addiction is increased for children that grow up in families that use illicit drugs and for adolescents that form friendships with illicit drug using peers.

Question 2

Describe the key risk and protective factors related to the development of addiction

Answer 2

protective factors:
-Social and emotional competence protective processes refer to actions to build competencies in areas that can reduce addictive behaviour. These include: goal setting; social skills training; relaxation and stress management; problem solving; and mindfulness skills that children and young people can learn that can reduce the harmful impact of risk factors. High intelligence and an easier child temperament may make it easier to develop social and emotional competencies.

risk factors:

According to this view, risk factors that emerge early in life (e.g., maternal smoking and alcohol use, child maltreatment) can lead to subsequent risk factors that tend to ‘adhere’ and accumulate as a consequence of the experience of earlier problems (e.g., school failure, antisocial friends and behaviour)

The snowstorm risk process occurs in communities that have high levels of child development hazards such as marketing by vested interests of substances. From this perspective, solutions lie in making communities safer for the healthy development of children and young people. Think of a snowstorm blizzard; even healthy children can be put at risk by dangerous conditions. If exposure to environmental hazards continues for long enough and the child has little protection, health and survival are placed at risk. Where the child has low protective factors (analogous to providing shelter in stormy weather: such as parents or community members being unavailable to supervise activities) in communities with easily accessed hazards (e.g., online access to substances), the likelihood of an adolescent succumbing to unhealthy outcomes increases

Risk processes for addiction in the antenatal (pre-birth) life stage

• Due to physical development risk processes, the risk of future substance abuse can be increased through foetal exposure to maternal substance use. Due to genetic and stress risk processes, a mother’s mental and physical health during pregnancy influences the child’s mental health and risk of addictions, while also influencing additional issues such as the risk of chronic illness.
• Risk processes that emerge in the young adult years include unsafe community risk processes such as exposure to poorly managed workplaces contributing to unsafe alcohol and entertainment environments contributing to substance abuse. Behavioural risk process theory posits that young adult outcomes for substance abuse are partly determined by progression in the development of these behaviours from the earlier adolescent and childhood periods. For some youth behaviours and lifestyles occur in the context of reproduction and child rearing. Where parents’ lives are unstable, chaotic or antisocial, children may experience conditions that promote stress risk processes or exposure to substances that trigger physical risk processes.
• With high rates of maternal alcohol use,

protective:
- Protective factors can occur for youth through social development processes whereby interaction with prosocial community members may moderate the effects of other developmental risk factors. Behaviour such as volunteering within effective mentoring and tutoring programs (such as Big Brother, Big Sister) enables youth to contribute a protective resource to their community by moderating the potential for negative outcomes for children and adolescents who have a high number of risk factors. The positive youth development literature conceptualises young people as a potential asset for building community social capital where their developmental trajectories have encouraged a sense of trust, and a commitment to become civically engaged to care for community members.

Risk processes for addiction in the school age life stage

• Many of the risk processes listed above can emerge in the adolescent years.
• Behavioural risk process theory posits that adolescent outcomes will be partly determined by progression in the development of the behaviours from the earlier childhood phase. For some adolescents, behaviours occur in the context of reproduction and child rearing with risks similar to those described above for young adults.
• Stress risk processes that emerge from the early years continue to operate during this period. Children and adolescents are increasingly exposed to stress risk processes in Australia given that child neglect and abuse notifications and substantiations have been steadily rising in most Australian jurisdictions in recent decades. Family conflict is a highly prevalent risk factor, with 33% of Australian children exposed to harmful levels.

protective:
Encouraging emotional competence and social development protective processes appears particularly relevant in this period and are also relevant in earlier phases of childhood. School connections are particularly important in this period.

-There is evidence that some aspects of substance abuse, mental illness, school failure, and antisocial behaviour can be prevented by addressing risk and protective factors in the middle years.

Snowball risk trajectories tend to be more common in disadvantaged communities, due to clustering from the early years of child stress, physical development, social development and unsafe community risk processes. Income inequalities have increased in Australia in recent decades and are reflected in location differences whereby some suburbs and neighbourhoods have high numbers of disadvantaged families living in close proximity. Rates of child and adolescent antisocial behaviour differed markedly between communities and are significantly higher in disadvantaged communities in Australia. In longitudinal research, community disorganisation and peer antisocial involvement (indicators of community disadvantage) have each been shown to be predictors of future adolescent substance use.
Social development protective processes can be effective in the preschool/early primary school period in increasing school and community prosocial bonding and thereby reducing the developmental effects of physical and mental health disability biologically embedded from earlier developmental periods.

Risk processes for addiction in the early years
-The early years (~0-3) includes the critical years from birth when the child is dependent on external support from the primary caregiver. There is evidence that contributions to preventing a range of problems including addictions can be made by addressing risk and protective factors in this period.

Child stress is a significant risk process resulting from distressing events such as child maltreatment. Community disadvantage tends to increase stress triggers such as domestic violence and child injury, with these problems more common in societies with larger income differences. Income inequalities and place-based disadvantage have increased in Australia in recent decades.

Protective factors include access to healthy behaviours such as breastfeeding, healthy food, and physical activity. The critical beginnings of social development protective factors are established in the early years through secure maternal-child attachment.

Question 3

Develop an understanding of components of effective prevention science interventions

Answer 3

Typically in treatment roles psychologists work one-to-one with a single client. However, when working in prevention interventions, psychologists are generally seeking to influence behaviour change across large populations. This can be done across the whole population (called universal intervention or primary prevention) or for groups who are at high risk (selective or secondary interventions). Although these two types of prevention are generally different to treatment (sometimes called tertiary prevention) or rehabilitation, overlaps can occur when the target is preventing addiction in the child of a substance addicted parent.

Interventions at the state and national levels

• Strategies that have evidence from overseas randomised trials and Australian evidence for feasibility include supportive home visiting to vulnerable parents to reduce snowball risk processes.
• the major structural interventions that have been proposed to prevent adolescent health priority problems are taxation reform to reduce economic access to alcohol and tobacco and increased industry regulation to control the marketing and availability of alcohol and tobacco.

pre-birth to pre-school interventions:

-Access from the antenatal period to early intervention services for genetic, medical and psychiatric conditions can moderate the influence of some family risk factors. Family interventions focus both on assisting parents to encourage healthy child and adolescent development and also assisting young people as they become parents. Parent education has been shown in randomised trials to be effective in in preventing adolescent alcohol, tobacco and drug use by reducing family risk factors and enhancing protective factors.

Effective intervention strategies include parent intervention programs to encourage healthy attachment through social development protective processes. Health service organisation strategies seek to ensure public health and provide targeted medical interventions that may address biological and genetic risk factors. Targeted strategies include family home visitation with disadvantaged families to reduce toxic stress and physical risk processes. Community mobilisation strategies in this period may effectively reduce unsafe community risk factors.

A strategy shown to be effective in reducing snowball risk processes in vulnerable adolescent parents include anti- and postnatal home visits by nurses and professionals. They are aimed at: supporting high-risk parents to develop good parenting practices, preventing child abuse, ensuring the child’s basic needs are met effectively, encouraging positive child–parent attachment, and supporting families who have problems associated with mental health or alcohol and drug use to ensure opportunities for healthy child development.

School age period interventions

-Effective intervention strategies targeting the middle years include parent education and school organisation programs to encourage social development protective processes and school curriculum interventions to promote emotional competence protective factors. Targeted strategies such as mentoring and cross-age tutoring may reduce the continuity of behavioural lifestyle risk processes and seek to reduce the progression of snowball risk trajectories. Community mobilisation strategies in this period can effectively reduce unsafe community risk factors.

Effective intervention strategies targeting the secondary school age period include school education curricula to increase emotional competence protective processes. Parent and school interventions and community mobilisation can encourage social development protective processes and reduce rates of teen pregnancy. More intensive strategies including family intervention, mentoring, and preventative case management may be promising strategies for encouraging social development to reduce the continuity of behavioural risk processes for adolescents who have a high number of risk factors.

Although school health curricula can offer benefits in encouraging adolescent health behaviour, school reorganisation whereby curricula are supported with teacher training and policy reform may offer greater advantages. The Gatehouse project was delivered in Australian secondary schools and included components addressing healthy school policies, teacher support and training and student emotional competence training. A randomised trial revealed that exposure to the intervention was associated with reductions in alcohol and tobacco use, antisocial behaviour and risky sexual behaviour (Bond et al., 2004).

Effective intervention strategies in the early adult age period are discussed in Topic 9 and include increasing the legal age for purchasing alcohol to 21, which would immediately reduce youth alcohol problems by more than 10% and be a major step to protecting Australia’s children from a major current threat. Increasing the price and regulation of alcohol can also reduce population rates of harm. Other strategies that can reduce harms in youth include brief interventions in primary health, education or employment settings aimed at reducing behaviour-lifestyle risk processes. Community mobilisation can be effective in this period to reduce unsafe community risk factors by increasing the enforcement of health and safety regulations in areas such as road safety, occupational health, and responsible service of alcohol.

How do we know interventions work? In the field of prevention science there are agreed to be three main levels of evaluation evidence that are sought relating to: efficacy; effectiveness; and dissemination (or translation) (Society for Prevention Research, 2015). Efficacy is generally demonstrated in evaluation studies that have high internal validity and therefore can convincingly identify causal relationships between the independent and dependent variable. Efficacy studies are often tightly controlled and hence do not have high external validity (real-world application). Effectiveness evaluations in contrast are run in real-world conditions and hence have high external validity. Evaluations of this type may for example measure behaviour change when programs with evidence of efficacy are delivered in randomly assigned systems such as schools or state agencies. Dissemination measures outcomes in large roll-outs such as state and national funding systems

Question 4

Develop an understanding of how to identify an ineffective intervention

Answer 4

Government policies that allow freedom to sell and market alcohol are clearly doing harm and increasing addictions in Australia and internationally. Alcohol is allowed to be sold or supplied: cheaply; to people known to have alcohol addictions and problems; to youth under 21; and by parents for their children. Prevention science can pinpoint how policies need to be changed.

Inadequate and ineffective policies for managing socioeconomic disadvantage contribute to increasing addictions in Australia and internationally. The gap between the richest and poorest Australians has been growing in Australia and in other nations in recent decades. This has resulted in an increasing number of families living in dysfunctional neighbourhoods with inadequate services and weakly performing schools. Living in these places can reinforce norms for heavy alcohol, tobacco and drug use and create underground economies based on supplying substances. Prevention science provides a means of developing and implementing policies and programs that reduce socioeconomic disadvantage and increase bridging social capital whereby the more affluent sections of society are guided to provide effective assistance to those not doing so well.

Sports clubs are a popular government investment for which land and facilities are provided with the idea that they encourage local people to get fit and socialize. Unfortunately, many sports clubs have norms that encourage high levels of alcohol, tobacco, drug use and gambling. Social development theory points out that social bonding to substance using and gambling sports stars increases pathways to addictions. Prevention programs such as Good Sports can reduce these problems.

Encouraging social relationships between groups of children and young people who have high levels of alcohol and drug use can result in peer influenced addictions. Schools that are poorly managed or that stream children according to academic problems are common and can increase peer influenced substance use.

Poorly devised behaviour change programs can be neutral or harmful. Parent training programs in the 1980s encouraged parents to teach their children to use alcohol moderately. These programs contributed to a population-wide increase in underage alcohol use in the 1990s across Australia. From 2002, prevention science efforts refocussed parent education messages to discourage underage alcohol use. Since that time rates of underage alcohol use have dropped across Australia.