The Drug and Alcohol Forum
APPLYING PREVENTION THEORY TO PREVENTION PRACTICE
by Ralph Tarter, Ph.D.
Director, Center for Education and Drug Abuse Research (CEDAR)
Western Psychiatric Institute and Clinic, Pittsburgh, PA
This article highlights a new classification of three types of prevention, focusing on specific types of population and the presence or absence of identifiable factors that require interventions. Universal prevention can be effective in reducing public health problems but is less effective in changing individual behaviors. Selected prevention targets particular characteristics of the individual that increase risk and must be tailored to capture the interests of high-risk individuals. Numerous risk factors are highlighted. These factors are understood to exist as a composite and for each individual comprise a unique combination. Prevention is required at an increasingly younger age to be effective. Indicated prevention is typically couched within the context of treatment; the line between prevention and treatment is ambiguous. The same risk factors described for selective interventions apply for indicated interventions the only difference is that in latter individuals the problems are more advanced.
After completing this article, participants will:
- Become familiar with the concepts of selective and indicated prevention
- Recognize social processes that increase risk status
- Be able to identify problems in targeting behavioral disorders with prevention strategies
The practice of prevention has historically been divided into three main categories. Primary prevention consisted of interventions that are directed at individuals prior to the onset of any signs of behavioral or medical disorder. Secondary prevention consisted of interventions directed at individuals who demonstrate early or prodromal signs of a disorder. Tertiary prevention consisted of interventions, more commonly called treatment, that are directed at individuals who manifest the disorder.
More recently, prevention practice has been redefined (Institute of Medicine, 1994). Three types of intervention were identified: Universal prevention consists of interventions directed at the whole population. Selective prevention is targeted to individuals who demonstrate the risk factors associated with a particular disorder. Indicated prevention consists of interventions directed at individuals who have a clinical disorder and, therefore, require professional attention.
The traditional and more recent classification of prevention strategies are not mutually exclusive. The newer classifications strategy is, however, more focused inasmuch as it specifies the type of population and the presence or absence of identifiable factors that require intervention. As research makes progress in elucidating the etiology of diseases of all types, prevention practice will accordingly become more specific. Thus, for example, universal intervention would entail applying techniques that are appropriate for the whole population where everyone is at elevated risk. Government regulations, for example, comprise a form of universal intervention to the population’s exposure to toxins and infectious agents. The prevention of behavioral disorders is in contrast more difficult because the causes are much more complex and tied to habitual lifestyle patterns. Nonetheless, exposure impacts on the whole population (e.g. drug availability in or near a school). Hence, administering a universal prevention, such as a school based intervention to a whole class or school can reduce the likelihood of initiation of the behavior (e.g. drug experimentation) which leads to the negative outcome. Similarly, the media campaign sponsored by the Partnership for a Drug Free America is a universal prevention. The importance of universal prevention is that it recognizes that everyone has some level of risk regarding the outcomes. At the least, universal preventions increase the consciousness of the population pertaining to the seriousness of the outcome disorder. Effective universal interventions thus shape attitudes and behavior.
It is well documented that universal prevention strategies can be effective. For example, they are generally credited with reducing the incidence of HIV infection in the gay population. From policy and fiscal perspectives, effective universal preventions are the most expeditious method of preventing disease or behavior disorder.
Universal preventions do not, however, work with the same effectiveness for the whole population. Thus, for example, HIV infection has not been reduced as significantly in the drug using population. Also, preventions illustrating the dangers of tobacco smoking despite extensive media campaigns and education programs have not been effective for youth (especially girls) even though adults have shown a dramatic decline in smoking. Numerous examples can be provided illustrating that universal preventions do not work equally for all individuals.
There are numerous reasons for the variation in effectiveness (Tarter, 1994). Not all individuals are at equal risk for developing the particular disease or behavior. Consequent to a unique genetic makeup, environmental factors, and developmental history, each person in the population has a different level of risk for manifesting the adverse outcome (e.g. unwanted pregnancy, crime, etc.). Persons at elevated risk are less amenable to universal preventions. Hence, despite widespread knowledge dissemination, public relations campaigns, and educational programming, a large proportion of the population engages in risky sex, has an unhealthy lifestyle, exercises poor nutrition, uses illegal drugs, as well as engages in injury-prone behaviors (e.g. driving without seatbelt fastened). For these individuals, intensive individualized prevention is required to effectively reduce or more hopefully ameliorate the risk. Toward this end, selective and indicated preventions are required. Their objective is to attenuate the likelihood of the adverse outcome by directly modifying the factors causing the heightened risk status.
If left unchecked, risk status may increase in severity over time as the result of the youngster’s expanding exposure to social opportunities (Tarter & Vanyukov, 1994). This augmentation of risk occurs in conjunction with two ongoing social processes: selection and contagion. Selection occurs when the person finds social niches in which other individuals share their personality, attitudinal and behavioral characteristics. This process is referred to as homophily. In colloquial language: Birds of a feather flock together. This social selection process is extraordinarily important with respect to preventing behaviorally determined outcomes (e.g. drug abuse, sexually transmitted diseases, pregnancy, etc.). From the standpoint of intervention, it illustrates that a necessary condition for effectiveness is to establish new social affiliation patterns. This may not be easy where the person is deemed to be deviant or undesirable. In effect, after a certain point, pursuing new social opportunities is not possible and the person becomes "boxed in" by their own characteristics and the negative perceptions of them by normative individuals.
In summary, considered within the developmental context, there is in high risk persons an unfolding and increasing augmentation of problems concomitant to voluntary exposure to social environments that perpetuate and exacerbate the person’s risk characteristics. Social selection implies an actively behaving individual who makes choices regarding their affiliation patterns. This includes the selection of friends, social opportunities, organizations for membership and our occupation. Social selection is not a random process. Rather, it is a function of the person’s psychological characteristics. Individuals who are sensation seekers, for example, are more likely to select social contexts where that behavior is accepted and rewarded. Not coincidentally, these environments provide easy access to alcohol and other drugs.
The second facet of social adjustment is contagion. This entails the extent to which individuals are influenced by the behavior, attitudes and values of others. This influence can include direct role modeling as well as initiation of behaviors observed through the media. It is clearly established, for example, that observing violence on television increases the likelihood of violence. Social contagion is a particularly powerful influence among adolescents. Those who are strongly susceptible to its influence may thus not be able to resist drug use by simply using refusal behavior or just saying "no" to drug offers. Individuals differ with respect to the influence of contagion (e.g. fashion, hairstyle, etc.). Together with social selection, it provides the basis for understanding the reciprocal and interactive basis of all social interactions.
Universal Preventions: What Do We Know?
Universal preventions have been extraordinarily effective in the field of public health. Examples include the reduction of medical and dental diseases associated with improved quality of drinking water. Vaccination programs attest to the huge success of prevention. Unfortunately, much less is known about prevention with respect to disorders that have a strong behavioral component. Significantly, most chronic diseases have a strong behavioral component, either with respect to their etiology or their maintenance. It is, however, extraordinarily difficult to modify behavior using only a universal approach because it is well recognized that sustained intensive intervention is required to achieve lasting behavioral change. Thus, whereas universal preventions can be effective, their adoption by the whole population for behavioral disorders is difficult. A notable exception is the reduction of smoking among adults during the past two decades.
It is noteworthy that there is an emerging literature suggesting that it is worthwhile to implement universal preventions even if only partially effective. This is important to note because even where the prevention is not entirely successful, approximations to success have a positive impact. For instance, less than 100% compliance for condom use poses some risk but also reduces risk of developing disease. Achieving only modest effects for reducing cardiovascular disease, injury or infectious disease in the general population translates to enormous health care cost savings.
Recent research, particularly in the field of drug abuse, demonstrates that tailoring universal interventions (Schinke, Botvin & Orlandi, 1991) to the particular characteristics of the individual may potentiate the effectiveness of prevention. For example, high sensation seeking youth respond more favorably to anti-drug media messages that have a high sensation seeking content which thus capture their interest whereas low sensation seeking youth are more attentive to drug abuse prevention messages that do not have a risk taking component. The point to be made is that not all individuals in the population respond to the same media message in the same fashion or with the same degree of effect. Hence, it is necessary to consider designing universal preventions, whether through media or didactic presentation, that adequately encompasses the variation in response to the message by particular individuals. To date, this strategy has not been systematically employed in drug abuse prevention, or, for that matter, prevention practice in general.
Selective Interventions: What Do We know?
A host of risk factors have been identified which are known to increase the risk in children for the development of a variety of outcomes. It is important to note, however, that these risk factors are nonspecific in that they do not portend a particular outcome. Rather, each risk factor is associated with a variety of outcomes with the specific disorder being manifest as a function of gender, socioeconomic status, social context, developmental history and personal characteristics of the individual. For example, a family history of alcoholism not only increases the risk for alcoholism in offspring but also is associated with an increased risk for conduct disorder, antisociality and depressive disorders. On the other hand, in some individuals, having a family history of alcoholism increases the resolve to prevent succumbing to this disorder. Thus, a given factor, even if it implies a future negative outcome need not necessarily operate in that fashion. Instead, there is strong scientific evidence illustrating that it is the total number of risk factors and not the presence or absence of a specific factor that determines outcome.
Numerous risk factors have been identified in youth at risk for the development of a variety of adverse outcomes (Hawkins, Arthur & Catalano, 1994). Considered collectively, these aggregating outcomes include drug abuse, teenage pregnancy, school failure, risky sex and associated outcomes (e.g. sexually transmitted diseases, HIV), criminality and school failure. The following categories of risk factors are noted, recognizing that they generally exist as a composite, and for each individual, comprise a unique combination. This defines ultimately our individuality.
Family-Genetic Risk Factors. A family history of a substance use disorder or psychiatric disorder is associated with increased risk for a disorder in offspring. However, it should be pointed out that typically less than 50% of children having a parent with such a disorder develop the condition themselves. In effect, parental or family history does not invariably lead to the negative outcome in the child, illustrating unequivocally that though risk status may be elevated, numerous intervening factors and processes occur such that the outcome can be prevented. Although exceptions occur, and the complexity of the relationships need to be emphasized, it has generally been reported in the research literature that paternal substance use disorder or antisociality transmits risk for these disorders in male offspring. Female offspring, on the other hand, tend to experience internalizing types of disorders, such as depression and anxiety. Apart from the risk associated with intrauterine exposure to alcohol or drugs, the literature on offspring of mothers with a substance use disorder does not indicate substantial elevated risk on offspring.
Biological Mechanisms of Risk. Numerous biological factors have been reported to augment the risk for an adverse outcome in children. For example, children who mature or reach puberty at a young age are at elevated risk. This appears to be due to the fact that their heightened physical appearance of maturity, combined with the lack of intellectual and social maturity, puts them at risk through association with older peers who expose them to risky situations.
At a more fundamental level, certain brain chemicals appear to be associated with increased risk. Particularly, individuals with low brain serotonin level present as impulsive and aggressive in many instances. Physiological factors in the form of heightened stress reactivity and inability to be calmed after stress appears to be associated with increased risk. Children who are hyperactive or have attention deficit disorder as well as neurodevelopmental disorders are similarly at high risk for future behavioral disorder. It is noteworthy that risk may also be elevated as a result of even subtle differences or characteristics. For example, individuals who are left handed not only have more adverse outcomes with respect to learning and academic potential, but it is significant to point out that for reasons as yet unknown, are over-represented in the alcoholic population.
Behavioral Risk Factors. Many behavioral risk factors have been reported to be associated with substance abuse and other outcomes. Temperament, for example, is a well-established risk factor, particularly where the child demonstrates the so-called "difficult temperament". This disposition is featured by high behavioral activity level, difficulty in socializing, low task persistence, high emotionality or irritability, and irregular sleep-wake cycles. Children with difficult temperaments, particularly where extreme, often manifest maladjustment at an early age which sets the trajectory for behavioral problems during childhood and ultimately early age exposure to alcohol and drugs. Along with these dispositional characteristics are impulsivity, sensation seeking, and aggressivity.
Although numerous psychological propensities have been found to be associated with elevated risk, it is well established that there is no single personality configuration or type that precedes the development of a substance use disorder. Hence, there is no addictive personality. This is not surprising because everyone in the population has a different personality makeup, and the fact that each of us has a unique genetic makeup, developmental history and environmental interactions.
Cognitive Risk Factors. Research has demonstrated that an individual’s beliefs about alcohol or drugs significantly contributes the likelihood that they will engage in consumption. Those who believe that these compounds are personally enhancing are more likely to use, and consequently a continued pattern of consumption puts that person at risk for developing an addictive disorder.
In addition to belief systems, it should be pointed out that many misattributions are made by individuals regarding the risk associated with their own behavior. This has been demonstrated by the fact that youth typically underestimate the risk of unprotected sex or not using seatbelts. They also underestimate the risk, or have misattributions, regarding the hazards associated with alcohol or drug use. This is very problematic for certain pharmacological agents, such as the inhalants, which are especially neurotoxic and in a short period of time produce massive brain damage. Similarly, the risks of cocaine use, particularly with respect to their potential to cause cerebrovascular disease, are commonly underestimated. Thus, misattributions of the safety hazards associated with the drug use are an important facet of cognition which need to be addressed in prevention.
Another facet of cognition pertains to executive cognitive functions. These neuropsychological processes refer to the capacity to strategically plan behavior, monitor behavior during goal directed motivation and, in effect, serve as a way of modulating the individual’s activities. These capacities are subserved by the prefrontal cortex of the brain which is most advanced in humans and the last part of the brain to mature postnatally. It has been shown that youth at high risk for substance use are deficient in executive cognitive functions. Low executive cognitive capacity is also associated with high aggressivity. As a result of this reduced capacity, high risk youth lack the ability to preview their behavior, or exhibit foresight with the same capability as normal youth. These neurobehavioral factors contribute to the risk for substance use in youth which are manifest especially in the form of lower executive cognitive functions. To date, prevention programs have not been specifically designed to address cognitive factors, although their importance is increasingly recognized.
Indicated Interventions: What Do We Know?
Indicated interventions are targeted to individuals who demonstrate a disorder requiring professional intervention. It is significant to note that during the past several decades, the age of onset of substance use has steadily declined and the interval between first use and dependence or addiction has shortened. These broadly defined secular trends indicate that preventions are required at an increasingly younger age in order to be effective. This observation is buttressed by the fact that even abusable compounds that are being broadly rejected by the general population are commonly abused by youth. For example, tobacco consumption has not declined significantly among youth and other forms of substance use appear to be on the rise.
Interventions in this framework are typically couched within the context of treatment (Tarter, 1995). However, the line between prevention and treatment is ambiguous. Children of alcoholics, for instance, commonly have severe problems that require professional intervention while at the same time require prevention of future addiction. The same risk factors described above for selective interventions apply for indicated interventions. The only difference is that in latter individuals the problems are more severe or advanced.
From the standpoint of prevention practice, the above general considerations yield the following conclusions. First, all prevention practice must necessarily involve the conjoint application of universal as well as targeted (selective and indicated) interventions. Second, prevention must consider not only the individual but also the social context in which that individual is operating with respect to contagion and selection influences. And third, prevention interventions must consider the developmental stage of the individual in gauging the extent to which the person is at elevated risk. This provides the opportunity to project the child’s future developmental trajectory. The premise behind all prevention is that the direction of the developmental trajectory can be re-oriented to positive outcomes following the implementation of an effective intervention (Kazdin, 1992).
Gordon, R., (1983). An operational classification of disease prevention. Public Health Reports, 98, 107-109.
Hawkins, J., Arthur, M., Catalano, R. (1994). Preventing substance abuse. Crime and Justice, 8, 197-277.
Institute of Medicine (1994). Reducing risks for mental disorders. DHHS Publication No. (ADM/87-1492), Rockville, MD, Dept of Health and Human Services.
Kazkin, A. (1992). Child and adolescent dysfunction and paths toward maladjustment. Targets for intervention. Clinical Psychology Review, 12, 795-817.
Schinke, S., Botvin, G., & Orlandi, G. (1991). Substance Abuse in Children and Adolescents, Newbury Park, CA: Sage.
Tarter, R. (1995). Rationale and method of client-treatment matching. The Counselor, 26-30.
Tarter, R. (1994). Rediscovering opportunities in the emerging health service environment. Journal of Clinical Psychology, 50, 111-113.
Tarter, R., & Vanyukov, M. (1994). Alcoholism: A developmental disorder. Journal of Consulting and Clinical Psychology, 62, 1096-1107
COMPLETE TEST FOR 1 PCACB–APPROVED CREDIT HOUR
(Record Answers for TARTER Test on Answer Sheet)
- The new classification strategy for prevention specifies which of the following?
a. Population and location
b. Factors requiring intervention and time
c. Population and factors requiring intervention
d. Population, location, and factors requiring intervention
- Which of the following is false? Universal interventions..
a. increase the consciousness of the population
b. recognize that everyone is at some risk
c. shapes attitudes and behavior
d. works equally for all individuals
- Prevention strategies do not include which of the following conclusions?
a. should include both universal and targeted interventions
b. considers the potential benefits achievable
c. considers the social context of the individual
d. considers the developmental stage of the individual
- Which of the following is false?
a. Each risk factor is associated with a particular outcome
b. Alcoholism increases the risk of alcoholism in offspring
c. Alcoholism increases the resolve to prevent succumbing to alcoholism in some offspring
d. The total number of risk factors determines outcome.
- Which of the following is not a risk factor for developing addiction?
a. Children who mature or reach puberty at a young age.
b. Low brain serotonin levels.
c. An addictive personality
d. A belief that drug compounds are personally enhancing.