More is Better

Print More

 

What’s better than a theoretically sound, research-tested, carefully implemented prevention program to reduce risky adolescent behaviors?

An integrated mix of several such programs concentrated within a single community.

That’s the uptake from the first rigorous multi-site outcome study of the Communities That Care community-wide prevention model, and from an innovative prevention initiative in upstate New York that has generated impressive results. Both projects appear to be achieving a result that has eluded even the most ambitious prevention efforts – improving success rates not only for a targeted group of participating youth, but for youths throughout a community.

“This shows that a coalition of community stakeholders armed with tools solidly grounded in prevention science can prevent middle schoolers from starting to use tobacco, starting to drink and starting to engage in delinquent behavior,” said J. David Hawkins, co-designer of Communities That Care (CTC) and lead author of the new outcome study. “That’s what’s really remarkable – that the effects are community-wide.”

Since the 1990s, CTC has been the most prominent community-wide methodology in the United States for preventing adolescent substance abuse and delinquency. Developed by Hawkins and Richard Catalano at the University of Washington’s Social Development Research Group, CTC provides an organized process to help communities take advantage of rapid advances in prevention science.

In CTC, community leadership teams are trained first to survey local youth populations and determine which critical risk factors and protective factors are most pervasive, then to select and implement proven prevention models targeted to address the identified needs. CTC’s Prevention Strategies Guide describes 56 school-based, community-based and family-focused programs that address one or more key risk or protective factors, intervene at developmentally appropriate ages, have been proven effective in high-quality evaluations, and offer detailed training and support to facilitate effective implementation.

Much of the research to develop, test and replicate the CTC model was underwritten by the U.S. Center for Substance Abuse Prevention, the Office of Juvenile Justice and Delinquency Prevention (OJJDP) and the Department of Education, and CTC provided the original basis for OJJDP’s Title V Community Prevention Grants Program that provided $243 million between 1994 and 2005 to help communities mobilize evidence-based prevention initiatives. (Since 2005, Congress has earmarked virtually all Title V funds for tribal justice, anti-drinking and gang prevention projects, leaving little or no funding to support community prevention efforts.)

Earlier studies in Washington state and in Pennsylvania found that CTC was effective in mobilizing community leadership teams and getting community leaders to undertake CTC training. They also found that CTC sites were more likely to adopt evidence-based prevention programs than were communities not employing CTC.

Until now, however, evidence demonstrating CTC’s impact on youth has been thin. An outcome evaluation in Pennsylvania – where more than 120 communities have implemented CTC – showed that school achievement improved and risky behaviors declined in communities implementing CTC, as did an earlier study in Buchanan County, Mo. But these studies did not employ strong experimental designs.

New evidence

The Community Youth Development Study, however, subjected CTC to the gold standard of evaluation research – a randomized trial. (Like outcome studies of many leading prevention models, this one was conducted by the program designers, rather than by independent evaluators.)

Funded primarily by the National Institute on Drug Abuse, the project involved a dozen matched pairs of communities in Colorado, Illinois, Kansas, Maine, Oregon, Utah and Washington, each of which was assigned either to implement CTC – and receive training plus up to $75,000 per year to implement model prevention programs – or to pursue their own prevention strategies without CTC support. The projects targeted youth ages 10 to 14.

The results were striking.

An initial implementation analysis found that the selected communities were pursuing CTC rigorously – each implementing an average of three model prevention programs per year, and doing so with high fidelity. These included teacher-led school-based programs like “Life Skills Training,” community-based youth programs like Big Brothers Big Sisters, and family-focused programs like “The Strengthening Families Program for Parents and Youth 10-14” and “Guiding Good Choices.” The outcome study, published in the September 2009 Archives of Pediatrics & Adolescent Medicine, shows that these efforts led to measurable improvements in the well-being of adolescents in CTC communities.

Based on annual surveys of more than 4,400 teens, the study found that youths in CTC communities were one-third less likely than youths in control communities to begin drinking alcohol or using cigarettes or smokeless tobacco between grades five and eight, and one-fourth less likely to start engaging in delinquent behaviors such as theft, vandalism and assault.

Among eighth-graders, youth in CTC communities were 23 percent less likely to report drinking alcohol in the previous 30 days, and 37 percent less likely to report binge drinking in the previous two weeks. The CTC eighth-graders reported committing 31 percent fewer delinquent acts than youth in communities not implementing CTC. Differences in marijuana and other drug use, while favoring CTC communities, did not achieve statistical significance.

“The results of this trial confirm that tools do exist that give communities the power to reduce risk for multiple problem behaviors across a community,” said Nora Volkow, director of the National Institute for Drug Abuse, when the CTC study was released.

The study does have limitations. All participating communities were independent and geographically removed small towns with their own schools and local governments, rather than cities or suburbs. Although some of those communities had high concentrations of Latinos and/or African Americans, overall, they were less racially diverse than the nation as a whole.

Nevertheless, the new study has escaped criticism, even from scholars who have expressed skepticism toward other programs claiming to be “evidence-based.” For instance, Texas A&M prevention expert Dennis Gorman has published a series of papers in recent years criticizing the research behind several of the prevention programs promoted under CTC, as well as early research for one model – the Seattle Social Development Project – developed by CTC founders Hawkins and Catalano. Yet, while stressing that he has not conducted an exhaustive review of the research on CTC, Gorman noted that he saw no obvious flaws in the CTC research methodology, and he said the underlying CTC model appears to be theoretically sound.

Another example

Further support for the potential of aggregating multiple evidence-based prevention programs in one locale comes from Partnership for Results, a community initiative in Cayuga County, N.Y., west of Syracuse. The initiative, developed by Philip Uninsky, a lawyer and sociologist, revolves around a county agency created to promote and coordinate a spectrum of evidenced-based prevention and intervention programs.

Since 1999, Partnership for Results has implemented more than 20 evidence-based programs to serve children and their families, including school-based and community-based interventions for youth from pre-school through high school.

Although Partnership for Results has not been formally evaluated, Uninsky reports that Cayuga County youths have seen substantially greater reductions in arrest rates and in hospitalizations resulting from assaults and self-inflicted injuries than their peers in other upstate New York counties. Cayuga County youths have also shown substantial declines in substance abuse and improvements in New York State achievement tests.

Partnership for Results was recognized in 2005 as one of the “50 Best Programs” nationwide in Harvard University’s annual Innovations in American Government Awards competition. Uninsky has been working with the city of Washington to replicate the partnership model.

While the Cayuga County approach differs from Communities That Care in important ways, both projects – like the Harlem Children’s Zone and the Obama Administration’s “Promise Neighborhoods” initiative – are cultivating a number of prevention programs side-by-side in the same communities.

“When communities choose and address two to five priority risk factors, in multiple domains of life, all at the same time in the same community, I think that has tremendous potential to improve outcomes for kids across whole communities,” Hawkins says. “We know how to do these things. But as a nation, we haven’t systematically empowered communities to do them.”