The first-ever Surgeon General’s Report on Alcohol, Drugs, and Health released in November 2016 was a call to action, providing specific steps that key stakeholders can take to address substance misuse. The report highlights how far we have come in both developing new knowledge about prevention, treatment, and recovery strategies and providing the appropriate clinical services to individuals at risk for substance use related problems. The report also emphasizes the importance of understanding the risk and protective factors that influence the likelihood of a young person first trying alcohol or drugs and the predictors of developing a substance use disorder, and the need for utilizing research to develop effective and tailored prevention or early intervention responses.
The Conrad N. Hilton Foundation’s Youth Substance Use Prevention and Early Intervention Strategic Initiative focuses on increasing access to effective early intervention by targeting settings where youth can be reached (schools, community programs, primary care and juvenile justice) and both providing training and information to youth-serving providers and caregivers and implementing a system of screening, brief intervention and referral to treatment, if needed. The Foundation’s initiative is poised to further a number of key findings in the Surgeon General’s Report as part of its strategic focus.
The initiative has had a tremendous reach since launching in 2014, screening almost over 61,000 young people across the U.S. for substance use and related health concerns and providing over 8,000 brief interventions. Additionally, over nearly 28,000 healthcare, school and community-based providers are now trained to administer screening, brief intervention and referral to treatment services to youth.
The initiative’s evaluation findings have consistently highlighted the need to identify and respond to emerging gaps in research and practice, especially as they relate to reducing health disparities among marginalized youth. To effectively address this recommendation, the Foundation is supporting efforts to reach young people from diverse backgrounds and is considering how to incorporate positive youth development (PYD) strategies that enhance protective factors and integrate wellness promotion when designing interventions. This article discusses the intersection of substance use and PYD strategies and highlights examples from the Foundation’s grantees and its early learnings from the initiative.
Substance use in adolescence is often linked to other risk factors or areas in a child’s life that need to be addressed before lasting reduction in substance use is possible. Issues such as depression, anxiety, stress, social or peer issues, familial issues, trauma, housing instability and lack of adequate nutrition are common risk factors. The disadvantaged, underserved and impoverished youth often endure combinations of these factors resulting in greater negative outcomes.
These risks don’t have the same impact on everyone; one child may turn to substances, another may turn to violence, while others with more supports and protective factors may not exhibit any negative impact. Risk factors can manifest in a multitude of problem behaviors (e.g. risky sexual behavior, self-harm or poor academic performance) and by screening only for substance use, without identifying the broader context of their lives, we may miss an opportunity to help youth navigate the issues they may be dealing with and the problem behaviors that could result. Substance use is an area that youth are also likely motivated to hide— it is illegal, can get them in trouble with school or parents, and may be embarrassing to admit.
Framing conversations about substance use in the context of overall health and wellness can help minimize the risk of young people becoming defensive or resistant, and increase the likelihood they identify any use as well as provide information on other issues that may be related to their substance use. By identifying and understanding the impact of risk and protective factors in their life, interventions can better prevent initiation or reduce escalation of substance use before it impacts other areas of healthy development, life satisfaction, achievement and overall wellness.
While addressing risk factors early is one good prevention mechanism, we must also address youth who need more proactive assistance by integrating PYD strategies. This approach complements primary prevention strategies— some of which the Foundation’s grantees are using to promote community level approaches and build strengths and competencies to minimize substance use related risks. Primary prevention and early intervention activities identify the risk factors that lead to problem behaviors and focus interventions on reducing those behaviors.
PYD goes a step further and emphasizes the plasticity of youth development. Based on the PYD framework, various individual and environmental interactions can result in positive development or problem behaviors. Thus, PYD interventions are tailored to individuals’ strengths to build competencies that enable more positive interactions with their environment, leading to healthier development across developmental domains (i.e. areas of development such as cognition, social/emotional and language/communication) rather than focusing on one specific behavior.
PYD improves competencies across the developmental domains listed above by providing youth with experiences that enable them to develop positive relationships and develop intentional self-regulation to set, prioritize, and achieve their goals. Studies on PYD and substance use show that intentional self-regulation enables youth to develop “the 5 C’s”–competence, confidence, connection, character, and caring. These skills contribute to reductions in an individual’s substance use and can lead to healthier choices and better decisionmaking.
One of the Foundation’s current grantees, YouthBuild, reaches young people who are at risk of substance use and other problem behaviors by integrating screening and early intervention into a comprehensive community-based approach. YouthBuild’s mission is to empower low-income youth through hands-on training and skills development in the construction field, where they build community assets like schools, playgrounds and community centers. They also receive social supports, and the program helps them develop character, competence and purpose while they contribute to their community. YouthBuild trains their staff to incorporate strengths-based conversations on substance use prevention and risk when they screen young people for alcohol and drug use. This approach increases protective factors while also addressing the underlying issues that lead to substance use.
Another grantee, the University of Vermont’s Wellness Environment (WE), led by Dr. Jim Hudziak, developed an intensive educational program for college students to provide them with resources and opportunities to successfully implement wellness strategies into their own lives. Students who choose to join the WE community live in separate drug- and alcohol-free residence halls and immerse themselves in an environment “where making healthy choices is the norm, not the exception.” WE emphasizes four key pillars of wellness— fitness, nutrition, mindfulness, and mentorship— and infuses these pillars through formal education. The program also delivers opportunities to incorporate the pillars into daily life with free fitness classes, cooking classes and “mindful” meal options, meditation classes, and community mentor partnerships. WE is a promising PYD program that enables young people to develop positive behaviors for wellness, including making healthy choices about substance use, while practicing these skills in their everyday lives.
Finally, the University of Minnesota is partnering with Kaiser Permanente through a grant from the Foundation to test a four-session intervention model that helps youth and parents understand and practice positive youth development strategies. The goal is to improve outcomes for youth who report mild-to-moderate mental health or substance use concerns and are referred to the project by pediatric providers and school personnel. The University of Minnesota is testing this multi-session model in an individualized intervention format, whereas Kaiser Permanente is testing the multi-session model in a group format.
The approaches discussed in this article have not yet been widely utilized by the substance use prevention community, but have driven significant reform in investments in other youth development fields like juvenile justice. Our early learning indicates there is real potential and interest in exploring how positive youth development and health and wellness approaches could be integrated with screening and early intervention to decrease youth substance use and support overall youth development and wellness. In the context of this Initiative, the Foundation and its partners are exploring a variety of ways to implement screenings “upstream” before crisis occurs to assess for risk and protective factors and target those most at risk of developing substance use disorders. Intentional self-regulation, the five C’s, and wellness education and promotion activities could be discussed in brief interventions and referrals. Going forward the Foundation will continue to explore PYD and how community partnership networks can be developed to connect and strengthen communities for greater youth impact.
Leigh Fischer, MPH, Dana Hunt, PhD and Bill Villalba, MA lead the Substance Use Prevention Strategic Initiative’s Monitoring, Evaluation and Learning team at Abt Associates, Inc.