Substance Abuse and Behavioral Health - Shared Risk Factors/Shared Prevention: Call for Collaboration Rob Lillis, Evalumetrics Research Lynne Gochenaur, LG Consulting & Training and Kim Strauser, Allegany Council on Alcoholism and Substance Abuse Rob

Public Health Model Interactive Comprehensive Cuts across issues/problems/disciplines Epidemiology Lynne The PHM addresses health or social problems in a comprehensive way. It considers human factors, characteristics of the source of harm and the environment identifying causes & potential ways to intervene.

Public Health Approach Surveillance Risk Factors (Root Causes) Intervention Program Implementation & Evaluation Lynne PHM starts with surveillance through data collection…..from there Identify causes of risk factors Develop & test interventions Implement interventions & measure prevention effectiveness

Unified Framework Lett, Kobusingye and Sethi Injury Control and Safety Promotion. 2002, Vol. 9, No. 3, pp. 199–205 Rob

Logic Model Problem (What?) Root Cause (Why?) Local Cause (Why here?) Action Plan Rob

Logic Model Why? Root Causes What? (Prevalence) Why Here? (Weighted factors) What? (Prevalence) Why Here? Local factors Implementation Evaluation Bullying Favorable Attitudes Toward Antisocial Behavior Friends Use Drugs Lack Belief in Moral Order Workgroup Input Develop Action Plan Evaluation Rob

Prevention Stratigies Population-wide influence System/culture change Environmental Host resiliency Inoculation Individual Lynne Environmental: Grounded in the field of public health Emphasizes the broader physical, social and cultural forces that contribute to problem behaviors. The goal is to change the context (environment) in which a problem occurs. Individual: Based on the premise that problem behavior develops because of deficits in knowledge, inadequate skill development and lack of positive attitudes toward self, family/peer and future.

Bullied Other Student One or More Time Past 30 Days Proportion at risk Proportion who bullied another student in past 30 days Evalumetrics Youth Survey - 2015 2015 not at risk at risk Ratio Favorable Attitudes Toward Antisocial Beh (R18-PI) 13.9% 27.4% 67.9% 2.48 Friend Use Drugs (R21-PI) 14.2% 28.2% 67.0% 2.37 Lack Belief in Moral Order (P11-PI) 7.5% 30.6% 72.1% 2.36 Interaction With Antisocial Peers (R20-PI) 12.4% 28.7% 65.8% 2.29 Favorable Attitudes Toward Drug Use (R19-PI) 13.4% 28.6% 65.5% Sensation Seeking (R22-PI) 29.9% 24.0% 54.8% 2.28 Rebelliousness (R14-PI) 17.2% 27.0% 61.4% 2.27 Impulsiveness (R16-PI) 16.2% 27.2% 61.8% Personal Transitions/Mobility (R3-C) 24.5% 53.6% 2.24 Parental Attitudes Favorable to Drug Use (R10-F) 14.7% 60.7% 2.11 Parental Attitudes Favorable to Antisocial Beh (R11-F) 10.9% 29.6% 2.09 Rewards for Antisocial Involvement (R23-PI) 12.2% 29.3% 60.5% 2.07

Predictors of Underage Drinking Proportion at risk Proportion that drank alcohol in the past 30 days. Evalumetrics Youth Survey - 2015 2015 Not at Risk At Risk Ratio Friend Use Drugs (R21-PI) 14.2% 17.2% 46.0% 2.67 Lack of Supervision and Rules (R6-F) 7.5% 18.6% 2.49 Sensation Seeking (R22-PI) 29.9% 14.3% 34.8% 2.44 Favorable Attitudes Toward Drug Use (R19-PI) 13.4% 17.4% 42.0% 2.41 Perceived Risks of Drug Use (P8-PI) 19.6% 16.9% 38.4% 2.28 Parental Attitudes Favorable to Drug Use (R10-F) 14.7% 17.5% 35.1% 2.01 Laws and Norms Favorable to Drug Use (R4-C) 18.1% 24.7% 47.8% 1.94 Favorable Attitudes Toward Antisocial Beh (R18-PI) 13.9% 18.4% 35.2% 1.92 Rebelliousness (R14-PI) 32.6% 1.81 Antisocial Behavior (R17-PI) 8.9% 19.1% 34.5% 1.80

Suicide Ideation (Made Plan in Past Year) Proportion at risk Made plan for suicide Evalumetrics Youth Survey - 2015 2015 not at risk at risk Ratio Favorable Attitudes Toward Drug Use (R19-PI) 13.4% 10.9% 38.9% 3.58 Rewards for Prosocial Involvement (P5-F) 20.4% 11.8% 35.3% 3.00 Opportunities for Prosocial Involvement (P4-F) 17.3% 12.5% 36.4% 2.92 Attachment (P3-F) 18.1% 12.7% 34.7% 2.74 Interaction with Antisocial Peers (R20-PI) 12.4% 14.0% 37.9% 2.72 Parental Attitudes Favorable to Antisocial Beh (R11-F) 14.3% 36.3% 2.54 Friend Use Drugs (R21-PI) 14.2% 14.1% 35.5% 2.51 Rewards for Antisocial Involvement (R23-PI) 12.2% 35.6% 2.49 Favorable Attitudes Toward Antisocial Beh (R18-PI) 13.9% 34.6% 2.46 Lack of Supervision and Rules (R6-F) 17.2% 13.3% 32.6% 2.44 Rewards for Prosocial Involvement (P7-S) 14.5% 35.1% 2.42

Priority Factors Across Problem Areas Evalumetrics Youth Survey - 2015 Summary Score Sensation Seeking (R22-PI) 8.63 Favorable Attitudes Toward Drug Use (R19-PI) 5.95 Friend Use Drugs (R21-PI) 5.75 Perceived Risks of Drug Use (P8-PI) 5.50 Rewards for Prosocial Involvement in the Family (P5-F) 4.54 Personal Transitions/Mobility (R3-C) 4.46 Rebelliousness (R14-PI) 4.09 Low Neighborhood Attachment (R1-C) 4.07 Little Commitment to School (R13-S) 3.98 Favorable Attitudes Toward Antisocial Behavior (R18-PI) 3.87 Parental Attitudes Favorable to Drug Use (R10-F) 3.84 Lack of Supervision and Rules in the Family(R6-F)

How Do You Get More Bang for Your Buck?? Activity I In small groups, discuss your assigned factor and document: What available activities/programs address your assigned factor: Directly? Indirectly? None/Little? Lynne

How Do You Get More Bang for Your Buck How Do You Get More Bang for Your Buck?? Activity I Example Risk Factor: Rebelliousness Directly: -MST - Functional Family Therapy - Positive Action Indirect: - Family/Parent Training - 21st Century Little/None: - Compliance checks - Party Patrols Lynne

Cost of Environmental Strategies $ Time Training Political chits Materials Maintenance Rob

Cost of Individual Strategies $ Time Training Political chits Materials Maintenance Lynne

Direct Impact of addressing a specific root cause: Environmental Strategies 1. Some direct impact Difficult to measure 2. Not likely to impact the hard-core who are disproportionately involved By missing the minority of the population you miss the majority of the problem 3. But…keeps the majority from entering the risk pool Rob

Environmental Strategy Example: Deterrence 3 Components of Deterrence: - Certainty - Speed - Severity Rob

Environmental Strategy Example: School Climate Change: Olweus Bullying Prevention Program Introduction of schoolwide rules against bullying Embed bullying prevention language in school district policies procedures for staff & students Refinement of school’s supervisory & discipline system Establishes core principles of bullying prevention through both environmental and individual strategies including: Lynne Develop partnerships with local community groups Weekly class meetings with students to build resiliency through discussion on bullying behavior

Direct impact of addressing a specific root cause: Evidence-based/Individual 1. Most direct impact Better able to measure impact 2. More likely to impact the hard-core who are disproportionately involved 3. Increase in dose increases impact “one shot” programs have limited impact Lynne Measuring impact – help rob! Evidenced-based interventions target biological, psychological and social factors that are more prominent in high-risk groups than among the wider population One shot interventions have been shown to do little to affect long term change.

Evidenced based/Individual: Positive Action Universal strategy utilized in schools and community-based settings Research-validated prevention program Social emotional learning program designed to increase positive behavior, reduce negative behavior & improve school & emotional learning. A classroom curriculum for grades K-6 Lynne Universal strategy utilized in schools and community-based settings Research-validated substance abuse prevention program proven to reduce the risks of alcohol, tobacco, drug abuse, and violence by targeting the major social and psychological factors that promote the initiation of substance use and other risky behaviors. Promotes healthy alternatives to risky behavior Provides enhancement of cognitive and behavioral competency to reduce and prevent a variety of health risk behaviors According to economic studies conducted by the Washington State Institute for Public Policy (WSIPP) researchers found that the LST program produced a $50 benefit for every $1 invested--yielding the highest return on investment of any substance abuse prevention curriculum studied.

Indirect Impact of Environmental Strategy: School Climate Change Olweus Bullying Prevention Program Greater commitment to school Decreased absenteeism Academic performance Emotional Competency Lynne

Indirect Impact of Evidence- based/Individual Mental Health Depression Suicide Bullying Self-injury Crime Antisocial Academics Drop out Academic failure Lynne Ultimately gets the best results by targeting risk factors

Collaboration Mapping ATOD Treatment Health Care Law Enforcement Antisocial Behavior <21 impaired driving Depression Alcohol Abuse Other Drugs Self Injury Bullying Collaboration Mapping ATOD Prevention Criminal Justice Lynne Let’s look at one specific risk factor: Antisocial behavior Antisocial behavior is a risk factor for not only for bullying but also Depression Bullying Self injury Alcohol abuse Other drug abuse When we look for collaborative partners, look for those whose primary problem area is also impacted by the same risk factor. Mental Health Schools Schools

Collaboration Level of Collaboration Coexistence Communication Cooperation Coordination Collaboration Functional Area: Strategic Planning Resource Acquisition Policy & Program Direction Staff Training Program Operations Disseminate Information Community Representation Community Leadership Program Evaluation Rob

Prevention Plan Strategy: Activity II Based on the work you completed in the first activity: Step 1. With the prediction chart for your root cause identify the problems that are predicted by this root cause Step 2. Based on the problems related to your root cause, who are potential collaborators/partners? Step 3. How do you build this collaborative with the identified partners? Where are you now, where would you like to be? Step 4. Groups report out Rob

Prevention Plan Strategy: Example Ratio (Over-involved) Drinking and Driving Depression Suicide Ideation Self Injury Bullying Sensation Seeking 3.97 1.33 7.53 1.31 2.15 Root Cause: Sensation Seeking Step 1: Identify the problems that are predicted by this root cause: Suicide Ideation (7.53) and Bullying (2.15) Step 2: Who are potential collaborators/partners: Mental Health and Schools Step 3: How do you build this collaborative with the identified partners? Where are you now, where would you like to be? Rob

Collaboration: Sensation Seeking Example Level of Collaboration Coexistence Communication Cooperation Coordination Collaboration Functional Area: ************** Strategic Planning MH Now MH Goal School Now School Goal Resource Acquisition Policy & Program Direction Staff Training Program Operations Disseminate Information Community Representation Community Leadership Program Evaluation Rob

Key Points By missing the minority of the population you miss the majority of the problem The root causes of your target problem are probably the root causes of other peoples target problem. Collaboration can take place on many functional levels. Vision Rob

What Have You Learned Dorothy? Spend your prevention resources where they do the most good. Be truly data driven. Evaluate from a cost-benefit model. Think outside the box…silo…funding tube. Public Health model! Rob

Contact Information Rob Lillis: rlillis@rochester.rr.com Lynne Gochenaur: lgochenaur@rochester.rr.com Rob

Prevention Plan Strategy: Activity II-A Root Causes of Problem Behavior Proportion at risk Drove after drinking Underage Drinking Bully Others Suicide Ideation Self-Injury Evalumetrics Youth Survey - 2015 2015 Ratio Favorable Attitudes Toward Drug Use (R19-PI) 13.4% 4.15 2.41 2.48 3.58 2.30 Root Cause: Favorable Attitudes Toward Drug Use Step 1: Identify the problems that are predicted by this root cause. Step 2: Who are potential collaborators/partners: Step 3: How do you build this collaborative with the identified partners? Where are you now, where would you like to be?

Prevention Plan Strategy: Activity II - B Root Causes of Problem Behavior Proportion at risk Drove after drinking Underage Drinking Bully Others Suicide Ideation Self-Injury Evalumetrics Youth Survey - 2015 2015 Ratio Antisocial Behavior (R17-PI) 8.9% 4.11 1.80 1.85 2.15 1.54 Root Cause: Antisocial Behavior Step 1: Identify the problems that are predicted by this root cause. Step 2: Who are potential collaborators/partners: Step 3: How do you build this collaborative with the identified partners? Where are you now, where would you like to be?

Prevention Plan Strategy: Activity II-C Root Causes of Problem Behavior Proportion at risk Drove after drinking Underage Drinking Bully Others Suicide Ideation Self-Injury Evalumetrics Youth Survey - 2015 2015 Ratio Lack Rewards for Prosocial Involvement in Family 20.4% 1.65 2.06 3.00 2.54 Root Cause: Lack of Reward Step 1: Identify the problems that are predicted by this root cause. Step 2: Who are potential collaborators/partners: Step 3: How do you build this collaborative with the identified partners? Where are you now, where would you like to be?