1. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 1 Broadening Prevention Research: Linking Schools, Families, and Communities in Promoting Positive Behavior, Character, Mental Health and Academic Achievement Brian R. Flay, D.Phil., FSBM, FSCRA, FAAHB Distinguished Professor Health Research and Policy Centers University of Illinois at Chicago Presented at American Academy of Health Behavior Conference in acceptance of the Research Laureate Award Napa, CA, March 25, 2002

2. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 2 Outline of Presentation 1. The importance of linking behavior, character, mental health, and academic achievement 2. Behaviors are related. Also predict and are predicted by each other Must work towards a comprehensive, coherent, integrated approach to youth development. 3. All behaviors have common predictors/causes Risk and Protective Factors The Theory of Triadic Influence (Integrates theories) Importance of Community, Family and School Must work toward comprehensive and coherent classroom, school-wide, family and community programs 4. Implications for prevention science, programs and policies

3. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 3 PART 1: The importance of linking behavior, character, mental health and academic achievement

4. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 4 Linking behavior, character, mental health and academic achievement are important because... Demands on education require that prevention be tied to academic achievement Most prevention and promotion programs to date have neglected the link with academic achievement –Exceptions: Hawkins & Catalano, Positive Action (Carol Allred), Weissberg’s recent statements re Social-Emotional Learning Academic Achievement depends, in part, on positive youth development –Most prevention researchers recognize that early school failure predicts later problem behavior, but rarely the reverse Prevention needs to fit into the whole educational picture of improving student behavior, character and achievement.

5. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 5 Other factors demanding positive youth development Most education dollars target reading and testing –E.g., $900 million to “Reading First” –This is probably short-sited –Education is in crisis Loud calls/demands for science-based programs of proven effectiveness –Is our science of effectiveness advanced enough? Increasing demands for community-based and after-school programs –Communities are in crisis –But don’t leave out schools. Education is key to youth development. Positive youth development = Positive behavior, character, mental health, academic achievement = A successful and happy life

6. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 6 Unfortunately... Behaviors that prevent success and happiness are far too prevalent among youth today Problem/Risky Behaviors –Substance use and abuse, violence, and unsafe sex Other health-compromising behaviors –Poor eating habits and inadequate physical activity Unacceptable and anti-social behavior Poor character development Psychological and mental disturbances School failure

7. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 7 Trends in Annual Prevalence of an Illicit Drug Use Index Eighth, Tenth, and Twelfth Grades, 1975-2001. Monitoring the Future data, http://monitoringthefuture.org

8. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 8 Violence among our Youth On a typical day, 6 or 7 youth are slain in this country, mostly inner-city, minority youth. Males account for more than 90% of incidents involving those 10-17 years of age. Handgun homicides committed by young males (15-18) between 1980 and 1995 increased by more than 150%. Youth are three times more likely than adults to be victims of violence. 5% of students reported feeling too unsafe to attend school at least once in the thirty days preceding the National Youth Risk Behavior Survey. 20% of high school students reported carrying a weapon (e.g., gun, knife, or club) at least once in the thirty days preceding the National Youth Risk Behavior Survey. ~8% reported carrying a gun, and 10% reported having carried a weapon on school property on one or more occasions in those 30 days. –Factoids from Center for the Study and Prevention of Violence, U Colorado, www.colorado.edu/cspv/factsheets

9. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 9 Teen sexual behavior? One quarter of high school freshman girls and just over half (52%) of senior girls have had sex. Almost a third (27%) of high school freshman boys and almost two-thirds (59%) of senior boys have had sex. Nearly 9 of 10 students enrolled in alternative high schools have had sex. Only about 1 in 5 young people do not have intercourse while teenagers. –Factoids from ETR: www.etr.org/recapp/stats

10. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 10 Mental Health Statistics for Children One in five children have a diagnosable mental, emotional or behavioral disorder. And up to one in 10 may suffer from a serious emotional disturbance (SGRMH, 2001). Attention deficit hyperactivity disorder (ADHD), one of the most common mental disorders in children, affects 3 to 5 percent of school-age children (NIMH, 1999). As many as one in every 33 children and one in eight adolescents may have depression, more likely for girls than boys (CMHS, 1998). Children and teens who have a chronic illness, endure abuse or neglect, or experience other trauma have an increased risk of depression (NIMH, 2000). Once a child experiences an episode of depression, he or she is at risk of having another episode within the next five years (CMHS, 1998). More than half of young persons with a substance abuse diagnosis also have a diagnosable mental illness (NAMI, 2001).

11. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 11 Conclusion #1: Prevention research, program development, and dissemination must –Link multiple behaviors with school success or failure –Link prevention with other educational functions (mental health and achievement)

12. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 12 PART 2: Behaviors are Highly Correlated

13. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 13 Substance Use and Abuse Behaviors are Highly Correlated and Predict Each Other Illicit Alcohol Tobacco Substance Ab/Use And can be thought of as a latent variable

14. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 14 Problem/Risky Behaviors are Highly Correlated and Predict Each Other Substance Ab/Use Tobacco Alcohol Illicit Weapons Inter- personal Violence Fighting Threats Unsafe Sex No Condoms Early Multiple partners Problem/ Risky Behavior

15. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 15 Mental Health Behaviors are Highly Correlated and Predict Each Other ADHD Conduct Disorder Anxiety/ Depression Mental Health

16. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 16 Health-Promoting Behaviors are Highly Correlated and Predict Each Other Health Care Hygiene Teeth Visits Physical Activity ExerciseWalking Sports Eating/ Diet Fruits & Veges Meat/Dairy Junk Healthy Behaviors

17. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 17 Conventional/Social Behaviors are Highly Correlated and Predict Each Other Academic Achievement Skills School Family Community Obey Rules and Laws Home School Community Bonding & Involvement Sport/ Cultural Service Voting Family School Conventional and Social Behaviors

18. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 18 Positive, Health and Social Behaviors are Highly Correlated and Predict Each Other Healthy Behaviors Conventional and Social Behaviors Eating/Diet Health Care Physical Low Risk, non-Problem Behaviors No Drugs Nonviolent Safe Sex Community Bonding Law Abiding Achievement Mental Health ADHA Conduct Anxiety /Dep Successful and Happy Citizens

19. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 19 Conclusion #2 Future prevention programs need to comprehensively and coherently address multiple behaviors and outcomes - Prevention of Problem/Risky Behaviors Substance use and abuse, violence, and unsafe sex - Promotion of health-enhancing behaviors Good eating habits and adequate physical activity - Psychological and mental health - Positive character development Positive moral and social behavior -School success

20. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 20 BUT, should we target single or multiple behaviors? - We used to believe that effects would be larger if we targeted a single behavior, or a single domain, such as substance use - Increasing evidence that many behaviors and domains are interrelated, and that programs should deal with them together - Increasing evidence that programs that address multiple issues are effective - Particularly if they address related issues -- problem behaviors, health behaviors, school behaviors

21. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 21 Two Programs As Examples ABAN AYA –Who: Flay et al., University of Illinois –What: Social & Emotional Skills Development Double Protection (ABAN) and Self-Determination (AYA!) –Why: Violence, Drug Use, Unsafe Sex –Where: Inner-city African-American Schools POSITIVE ACTION –Who: Carol Allred, Twin Falls, ID –What: Comprehensive Character Education & SEL –Why: Improve all behaviors and academics –Where: 8,000 schools nationwide and internationally

22. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 22

23. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 23 ABAN AYA Classroom Content INFORMATION –Prevalence and nature of risky behaviors –Consequences of engaging in risky behaviors –On the proper use of medicines SOCIAL INFLUENCES –Awareness of social influences from peers, family, media, etc –Corrections of normative misperceptions PROBLEM SOLVING –Decision making –Goal setting SOCIAL SKILLS –Assertiveness/Resistance skills –Risk management or avoidance –Conflict resolution, mediation –Social networking CULTURAL PRACTICES AND VALUES –Cultural pride/history (Kwanzza - Nguzo Saba) –Articulation of community roles

24. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 24 Violence: Predicted Means

25. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 25 Substance Use: Observed Means

26. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 26 ABAN AYA significantly improved multiple behaviors Physical Violence Provoking Behavior Alcohol and Drug Use School Delinquency Frequency of sexual intercourse Condom Use Healthy & junk food consumption Physical Exercise Standardized Test Scores

27. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 27 ABAN AYA significantly improved multiple behaviors … Though only for males! Physical Violence Provoking Behavior Alcohol and Drug Use School Delinquency Frequency of sexual intercourse Condom Use Healthy & junk food consumption Physical Exercise Standardized Test Scores

28. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 28 Males’ behavior was brought down to the level of females’ behavior

29. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 29 After adjusting for pretest differences, there were also effects on standardized test scores (males & females)

30. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 30 The Positive Action Program Targets Multiple Behaviors By teaching that doing positive actions helps: –individuals develop a positive self identity. –families develop a positive family identity. –schools develop a positive school identity. –communities develop a positive community identity. By teaching that: –When you do good, you feel good

31. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 31 In the classroom curriculum and in all other materials, the Positive Action content is taught school-wide through six units: Unit 1. Self-Concept: What It Is, How It’s Formed, and Why It’s Important. Unit 2. Physical and Intellectual Positive Actions for Body and Mind Unit 3. Social/Emotional Positive Actions for Managing Yourself Responsibly Unit 4. Social/Emotional Positive Actions for Getting Along with Others by Treating Them the Way You Like to be Treated (Character Education) Unit 5. Social/Emotional Positive Actions for Being Honest with Yourself and Others (Mental Health) Unit 6. Social/Emotional Positive Actions for Improving Yourself Continually

32. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 32 And Has Multiple Effects:

33. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 33 PART 3: All Behaviors Have Common Predictors/Causes

34. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 34 All Behaviors Have Common Causes PERSONAL Genetic Personality SELF-EFFICACY SITUATIONAL Community Family School SOCIAL NORMATIVE BELIEFS ENVIRONMENTAL Broader socio- cultural environment VALUES/ ATTITUDES

35. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 35 All Behaviors Have Common Causes: The Basics of the Theory Of Triadic Influence BEHAVIOR Decisions/ Intentions & Personality Biology Sense of Self Social Skills Self Determin- ation SELF EFFICACY Social Competence DNA

36. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 36 Not to be confused with... my Audi TT

37. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 37 References re TTI Petraitis, J., Flay, B.R., & Miller, T.Q. Reviewing theories of adolescent substance abuse: Organizing pieces of the puzzle. Psychological Bulletin, 117(1), 67-86. 1995. Flay, B.R. & Petraitis, J. The theory of triadic influence: A new theory of health behavior with implications for preventive interventions. In Albrecht, G.S. (ed.) Advances in Medical Sociology, Vol IV: A Reconsideration of models of health behavior change (pp. 19-44). Greenwich, CN: JAI Press, 1994. Flay, B.R., Petraitis, J., Hu, F. The theory of triadic influence: Preliminary evidence related to alcohol and tobacco use. In Fertig, J.B., Allen, J.P. (eds.) NIAAA Research Monograph - Alcohol and Tobacco: From Basic Science to Clinical Practice (pp. 37-57). Bethesda, MD: U.S. Government Printing Office, 1995. Flay, B.R. Understanding environmental, situational and intrapersonal risk and protective factors for youth tobacco use: the Theory of Triadic Influence. Discussant Comments. Nicotine & Tobacco Research, 1, S111-S114, 1999.

38. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 38

39. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 39 “All Behaviors Have Common Causes” National Socio-Cultural Environment Political, Economic, Media, Religious. Values, Attitudes Local Community, Families, Schools Relationships with Others. Others’ Attitudes, Behaviors. Social Normative Beliefs Self-Concept, Social Skills. Self-Efficacy Intrapersonal Biology, Personality Risky Behavior, Healthy Behavior, Mental Health, Academics EVERYBODY NOW ….

40. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 40 All Behaviors Have Common Causes National Socio-Cultural Environment Political, Economic, Media, Religious. Values, Attitudes Local Community, Families, Schools Relationships with Others. Others’ Attitudes, Behaviors. Social Normative Beliefs Self-Concept, Social Skills. Self-Efficacy Intrapersonal Biology, Personality Low Risk, non-Problem Behaviors Nonviolent Safe Sex Successful and Happy Citizens Conventional and Social Behaviors Community Bonding Law Abiding Achievement No Drugs Health Care Physical Healthy Behaviors Eating/Diet Health Care Physical Mental Health Eating/Diet

41. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 41 BUT, Note the Critical Importance of Community, Family and School Community Family & School Relationships with Others. Others’ Attitudes, Behaviors. Social Normative Beliefs Values, Attitudes Self-Efficacy Risky Behavior, Healthy Behavior, Mental Health, Academics

42. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 42 The Critical Importance of Community, Family and School Community FamilySchool Student Health, Behavior and Academic Performance

43. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 43 Conclusion #3 Future prevention programs need to involve whole schools, families and communities in an integrated and coherent way - Classroom curricula can teach content and skills Should be school-wide, scoped and sequenced for every grade - Teacher training can address class/behavior management and teaching effectiveness - School-wide climate change can provide a safe learning environment provide common language and consistently reinforce desired behaviors - Family programs can improve parenting skills provide common language and consistently reinforce positive behaviors - Community programs can link schools and communities get students observing and doing community service provide common language and consistently reinforce positive behaviors

44. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 44

45. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 45 Comprehensive classroom program Enhanced parent involvement Parent Training/Education School Health Promotion Task Force School-wide staff development Community-Based Organization involvement Institutionalization in schools & communities ABAN AYA : INTENSIVE SCHOOL/COMMUNITY INTERVENTION

46. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 46 ABAN AYA: SDC and SC Effects on Males by 8th Grade

47. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 47 The POSITIVE ACTION Program Components K–12 classroom curriculum over 1,200 lessons - using Teacher’s Kits (manuals and materials for each grade), classroom teachers present 15–20-minute lessons Principal’s Kits (Elementary and Secondary) a school-climate program to promote the practice and reinforcement of positive actions in the whole school population (students and staff) Counselor’s Kit used with selected individual students, small groups and families Family Kit contains prepared weekly home lessons paralleling the school program along with school parent-involvement activities Community Kit manuals and materials that align and encourage collaboration of all the environments (schools, families and community) involved in the program

48. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 48 And Has Multiple Effects:

49. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 49 PART 4: Challenges for Prevention Science, Prevention Programs and Education

50. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 50 Is Prevention Science Up To The Challenges Of...? Developing comprehensive interventions That are multi-component, broad-based, deep-structured, and coherent Evaluating comprehensive interventions Is very difficult and complex And is very expensive Getting schools to do the seemingly impossible Be successful in improving multiple behaviors as well as character and achievement Translating research into practice So that it is replicable

51. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 51 What’s at stake if we don’t meet these challenges? Disenchantment with prevention The credibility of prevention researchers Prevention funding for schools Increased problems for our children More adolescent SU, violence, unsafe sex Declining virtues, morals, etc. Decreasing academic achievement and increasing school failure Increasing failures to succeed in life

52. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 52 Limitations of Most Programs Domain Specific –Usually only one behavior or one skill Start too late –Upper elementary or middle school Limited intensity and dose –Often only once a week for 10-20 sessions Ecologically Limited –Usually only classroom. –Also need school-wide, parent, community Limited Effect Sizes –Average effect sizes in the 0.2 to 0.4 range Effects not Sustained –Few effects beyond one year, let alone H. S.

53. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 53 Conclusion #4 All of the foregone has implications for: –Prevention and Education Programs –Prevention and Educational Policy –Prevention and Education Research

54. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 54 Promotion Programs of the Future Must Be Characterized As … EARLY AND OFTEN –Start early, scoped and sequenced, many doses, over a long time POSITIVE –Focus on asset and strength development –Address protective factors more than risk factors –Include positive reinforcement and environmental contingencies COMPREHENSIVE –Multiple domains: behaviors, feelings, thoughts, character, achievement –Multiple protective/risk factors –Multiple levels: students, teachers, school, families, community REPLICABLE –Diverse teaching strategies –Complete materials, user friendly –Minimal training required, but necessary training easily provided EFFECTIVE –Large effects that are sustained

55. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 55 Future Educational Promotion Policy Must... Focus on positive child/youth development Rather than focusing on negative behaviors and failures Prefer more integrated, comprehensive, coherent, holistic approaches Rather than separate, piece-meal approaches to different issues Support longer-term, more comprehensive research/evaluation Rather than shorter-term, limited studies This will require prevention/promotion to align with character education and achievement

56. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 56 Future Promotion Researchers will... 1. Analyze for whom programs are most and least effective. 2. Conduct mediation and other analyses to help us understand mechanisms of action. 3. Show long-term effects with school-level data. 4. Have a broader view of acceptable approaches to research. 5. Consider larger replicated effects to be more important than findings from any one study. 6. Conduct more effectiveness trials. 7. Conduct cost-effectiveness analyses.

57. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 57 Not OR but AND Science AND Passion Risk Factors AND Protective Factors White, middle-class AND Diverse cultures Genetic/Intrapersonal AND Social/Environmental Individually focussed AND System/Environment Research Based AND Real World Derived Scientific Rigor AND Program Characteristics Courtesy Tony Biglan and colleagues, Stanford Center for Advancement of Behavioral Sciences, 3/01

58. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 58 SUMMARY It is critically important to link behavior, character, mental health, and academic achievement Positive, problem, health, and mental health behaviors are all related, and are all related to character and academic achievement All behaviors and related outcomes have the same causes, many of which reside in families, schools and communities Future prevention/promotion research, programs, and policies need to be comprehensive, integrated and coherent across behaviors, grades/ages, and social ecologies (schools, homes and communities)

59. UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 59 Have A Positive Action Evening. And A Happy and Successful Life.