Innovations in Prevention: Youth Substance Abuse & Dating Violence

1. Innovations in Prevention:
Youth Substance Abuse & Dating Violence
Christine Wekerle, Ph.D.
The University of Western Ontario
cwekerle@uwo.ca
“ Violence in intimate relationships can be
one…in which great intensity of positive
longing, anger, and fear may be combined
with a lack of felt security, lapses in
attention, dysfluent communication, and
unregulated arousal.” (Lyons-Ruth & Jacobvitz, 1999)

2. Similar Examples:
Different Outcomes
• Developmental context – relationships
• Perhaps type of relationship - attachment
• Topographically similar events
• Functionally similar behaviours – to a point
• Affectively similar – to a point
• Good cognitive awareness of event
• How to change? Motivation to change?
• Would change or self-correction occur on
its own?

3. Natural Reduction Processes
Teens who stop drinking (D’Amico et al., 2001; Brown, 2001)
1. Independent Effort (willpower, forced myself)
2. Structured Activity (sports, hobbies, church)
3. Social Support (family, new friends)
• High school binge-drinkers who refrained from binging
(past 3 months) in college did not differ in drinking
milestones or severity of substance use from current
bingers
• Natural reducers in college were, on average, 3 years
older, more likely to be married, regular church go-ers,
greater belief in ability to resist social pressure to drink,
less ambivalence about changing drinking, and expected
alcohol to enhance their personal experiences less
(Vik et al., 2003)

4. Universal Prevention
Interventions that target the whole population that
has not been identified on the basis of individual risk
Goal = to decrease the number of new cases
(decrease incidence of disorders)
• 52% of youth have no risk behaviors (OSDUS,
2003)
• A minority of high school youth may volunteer for
intervention on drinking prevention (e.g., 10% of
4500 students in 3 schools, D’Amico et al., 2001)
Query: How to reach more youth? (e.g., building
into school curriculum; use medical settings)

5. Selected Prevention
Interventions that target individuals or sub-groups
with at-risk status
Goal= to lower the number of established cases
(decrease prevalence of disorder)
• 20% of children/youth experience past year
mental disorder symptoms and 75-80% of these
fail to receive services (USDHHS, 1999)
• 28% of youth report 1 problem behaviour
• 10% of youth report 3-4 problems
(OSDUS, 2003)

6. Key Windows of Opportunities
1. Perinatal and Early Childhood
Programs targeting parents, infants,
young children
2. Education Programs targeting
school-age children and teens

7. Distal Factor: Child Maltreatment
Effective parenting is the most powerful way to reduce youth
problem behaviours (Kumpfer & Alvarado, 2003)
Child maltreatment may be the single most preventable and
intervenable contributor to child and adult mental illness
(DeBellis, 2003)
Violence victimization is associated with a lower age of
drinking initiation (Nagy & Dunn, 1999)
You know the only people who are always sure about
the proper way to raise children? Those who’ve
never had any. Bill Cosby

8. Substance-Abusing Caregivers
Reported to Child Welfare
– Poverty (income < $15,000, OR=1.6)
– Multiple moves in the past 6 months (3+, OR=5.2)
– Unsafe housing (OR=1.9)
– Minority racial status (Aboriginal OR=3.4; Other
Minority OR=1.4)
– Low caregiver education (OR=1.9)
– Criminal activity (OR=4.8)
– Involvement in a violent relationship (OR=3.8)
– History of childhood maltreatment (OR=3.2)
– Mental (OR=2.8) and physical (OR=2.6) health
issues
– Lack of social supports (OR=2.6)

9. Canadian Incidence Study of Reported Child Abuse & Neglect:
Caregiver Substance Abuse
65%decrease
OR: 0.35; CI: 0.14, 0.90*
61%increase
OR: 1.61; CI: 1.17, 2.21*
155%increase
OR: 2.55; CI: 1.90, 3.42*
6%decrease
OR: 0.94; CI: 0.63, 1.41
-150%
-100%
-50%
0%
50%
100%
150%
200%
Physical abuse Sexual abuse Neglect Emotional abuse
ChildMaltreatment Type
%increase/decreaseinriskformaltreatmentin
associationwithcaregiversubstanceabuse
age & sexof the child + the caregiver's characteristics accounted for *p>0.05

10. Child Maltreatment & Prevention
– Lack of adoption of evidenced-based
parenting programs by community
agencies (Kumpfer & Alvarado, 2003)
– Child welfare youth important, but under-
attended subpopulation for prevention
– Need to show change in child abuse rates
due to prevention parallel change in
adolescent risk behavior rates in same
community/population

11. Assessing Impact:
Community Report Card
• Useful tool for impact evaluation Create a relevant
surveillance system beyond problem behavior rates
e.g., percentage of schools with prevention
programs; youth recreation space; rate of youth
unemployment, per capita spending on support
services
• Link data bases that track health services utilization
with community child abuse reporting rates,
educational testing outcomes
• see Strike, C., Goering, P., & Waslylenki, D. (2002). A population health framework for
inner-city mental health. Journal of Urban Health: Bulletin of the New York Academy of
Medicine, 79, S13-S20.

12. Effective Prevention:
What You Need To Know & Why
Baserates of problem behaviour 
Outcome Targets
Inter-relationships of behaviours 
Multiple Targets
Developmental trajectories 
Developmentally-
timed intervention
Explanatory factors: Mediators 
Change Targets
Contextual factors: Moderators
Matching to sub-
groups

13. Baserates: Youth Substance Abuse &
Dating Violence
• 21% males; 17% females report hazardous
drinking
• 24% report drunkenness past month
• 26% binge drink past month
• 10%, 2-3 binge episodes/month
• 8% weekly; 4% daily marijuana use (OSDUS,
CAMH, 2003)
• 8.9% physically assaulted in dating
relationship past year
• 11.9% females; 6.1% males ever forced into
sexual intercourse (YRBSS, CDC, 2003)
• 19% emotional abused (ADDHealth, Carver
et al., 2003)

14. Points for Developmental
Timing
Developmental Tasks:
–Emotional Autonomy
–Behavioural Independence
–Identity
–Sexuality & Romantic Relationships
–School Achievement & Career Planning

15. Stages of Change (Transtheoretical Model of
Change; Prochaska, DiClemente, & Norcross, 1992)

16. Stages of Change

17. Change Targets: Motivation
Motivational Interviewing= Client-centered, directive
method for enhancing intrinsic motivation to change by
exploring and resolving ambivalence (Miller & Rollnick, 2002)
• Motivation regarded as a state not trait
• Non-”hard” confrontational yet directive
• Responsibility for change rests with youth
• Highlights the need to consider motivation explicitly as
a target in prevention programming
Motivation for what specifically?
• Pre-use: motivation to abstain or delay use
• Once engaged: to refuse, to avoid, to reduce, to do healthier
alternative

18. Motivational Interviewing Key Tool:
Decisional Balancing
Develop Ambivalence about Use
• Tailored to stage-of-change
• Discrepancy=motivation
• Discussion on pros and cons of
use (likes/dislikes)
• Providing normative feedback
• Imagine future if behavior stay
same or were to change (future
goals)
• Help client identify and clarify their
own goals and values so that
discrepancy is related to what is
important to the teen
• Teen presents the reasons for
change

19. Change Targets:
Pattern of Reinforcers
• Behavioral Choice Theory: Draws attention to the relative
reinforcement attained from behavior within the context of other
reinforcers that predicts substance use/aggression (preference,
Vuchinich, 1995)
Factors that influence consumer behavior:
– Direct constraints on access to the reinforcer (e.g., if
dating partner leaves when threatens aggression; can’t
acquire alcohol due to being under legal age of drinking)
– Availability of alternative reinforcers and constraints on
access to them (e.g., talk to friend about conflict and friend
is readily available; exercise instead of use alcohol with
highly valued exercise readily available)

20. Mediators: PTSD Symptomatology
DSM- IV Symptom Classes:
(1) Re-experiencing: recurrent, intrusive thoughts;
bad dreams*; sense of re-living*; physiological
reactivity and psychological distress* at cue
exposure
(2) Avoidance/Numbing*: avoid thoughts, feelings,
places, people, activities related to trauma*; gaps
in recall; feeling detached; feeling problems;
pessimism about future
(3) Arousal: sleeping, anger, irritability, startle*,
hypervigilance, concentration difficulty
* Higher among chronic, abused youth (Fletcher,
2003)

21. Cross-lagged Structural Model Of Trauma Symptoms As A Predictor Of
Child Maltreatment And
Dating Violence For Boys, Adjusted To Include Independent Mediator
Paths For Emotional Abuse
Time 1 Time 2
.23**
.62**
.32**
Child Mal-
treatment
Trauma
Symptoms
Trauma
Symptoms
Dating
Violence
Dating
Violence
Emotional
Abuse
Emotional
Abuse
.25**
.25**
.38** .41**

22. Cross-lagged Structural Model Of Trauma Symptoms As A Predictor
Of Child Maltreatment And Dating
Violence For Girls, Adjusted To Include
Independent Mediator Paths For Anger
Time 1 Time 2
.23**.22*
.75**
.58**
.20**
.19**
.52**
Child Mal-
treatment
Dating
Violence
Dating
Violence
Trauma
Symptoms
Trauma
Symptoms
Anger Anger
.25**
.16*

23. Dating Violence Prevention:
The Youth Relationships Project
Rationale: Youth with a child maltreatment history at greater risk
for relationship violence
Target Age: Mid-adolescence (age 14-17) [By age 14, 55% had
romantic relationship; by 17, 80% had romantic relationship,
Carver et al., 2003]
Targets: (1) concept of relationships
(2) relationships skills
(3) social action (mastery via advocacy)
Program: 18 sessions (2-hr) coeducational group format,
coeducational facilitation – semi-structured manual
Results: Reduced dating violence involvement, Reduced PTSD
symptomatology within a RCT design with child welfare youth
(Wolfe, Wekerle et al., 2003)

24. Youth Prevention Information Sources
(see American Psychologist, 2003, vol. 58)
Lists of Effective Prevention Programs:
Center for Substance Abuse Prevention
Centers for Disease Control and Prevention
National Institute on Drug Abuse
US Department of Education Office of Safe and
Drug-Free Schools
Surgeon General’s Office
Office of Juvenile Justice and Delinquency
Prevention

25. Conclusions
• Need to consider utility of dual or multi-targeting targets for
prevention based on demonstrated co-morbidities
• Need for broader surveillance on dating violence behaviors
• Need for teen violence prevention to consider applicability of
effective substance abuse prevention components e.g.,
motivational interviewing, beliefs about/motives for aggression
• Need for substance abuse prevention to consider issues
stemming from violence work, such as child maltreatment
history, PTSD
• Need to understand better SES, gender, ethnicity/culture as
moderators of outcome and adaptation to important subgroups
e.g., child welfare youth
• Need to demonstrate efficacious prevention through population
surveillance