. . . let us try to offer help before we have to offer therapy. That is to say, let’s see if we can’t prevent being ill by trying to offer a love of prevention before illness.
—MAYA ANGELOU
A new flood was predicted and nothing could prevent it. In three days, the waters would wipe out the world.
The Dalai Lama appeared on worldwide media and pleaded with humanity to follow Buddhist teachings to find nirvana in the wake of the disaster.
The pope issued a similar message, saying, “It is still not too late to accept Jesus.”
The chief rabbi of Jerusalem took a slightly different approach. “My people,” he said, “we have three days to learn how to live underwater.”
—YIDDISH JOKE
To recognize the salience of prevention, we need to think of it not as an “ounce” but something closer to a “ton.”
For twenty years, from 1989 to 2008, California invested $2.4 billion of its tax dollars from cigarette sales in what was called the California Tobacco Control Program. The money was spent on efforts to reduce smoking, including funding community coalitions that sought to implement no-smoking policies and practices, as well as on informing public-media campaigns.
An analysis of this investment performed by the University of California, San Francisco, considered changes in smoking prevalence, cigarette consumption, and health-care costs: $134 billion was saved by the program, producing a 5,500 percent return on investment (ROI) from reductions in the cost of treatment of smoking-related illnesses.
Youth are especially prone to using alcohol, drugs, and tobacco. Experimentation is normative, as is risk taking and the drive to defy authority as a path to independence. Moreover, the capacity of the brains of youth to control their impulses and behaviors is biologically limited because, as noted earlier, myelination is still under way. Finally, peer and media influences are everywhere, especially those pro-drug messages in music, TV, and movies. We can expect substance use and will likely continue to see it widely. Our collective work and responsibility is to limit its damages.
Three levels of action, or intervention, have characterized scientific writings on prevention, including prevention of behavioral health conditions like addictions. This construction builds on public-health principles that consider a population—an aggregate group—of people, some at risk of a condition and some not. These definitions are described here more specifically for populations of youth.
Universal programs aim to reach all youth, whether they are at known risk or not. These are also known as primary, universal prevention. Selective programs aim to reach youth exposed to known and high levels of risk for a condition, but who have not yet become symptomatic. These are also known as primary prevention for at-risk groups. Indicated programs are those that aim to serve youth showing indicia of early behavioral health problems, and are sometimes called secondary prevention.
As we dig more deeply, an understanding of prevention is nicely illuminated by a model that divides individuals according to their unique characteristics in two key ways: risk factors and protective factors. These are the yin and yang of prevention.
Risk factors are those environmental, familial, or individual elements that carry greater risk for promoting a health problem, in this case a substance use disorder. Protective factors, similarly, exist outside and inside all of us and can reduce the potential for problem substance use and abuse. Risk and protective factors vary from one person to another and can change over a person’s life.
Adding to this perspective, which is useful in policy and program development, we can consider risk and protective factors by “domain”—namely, wherein the locus of the problem or intervention may principally be located.
Risk and Protective Factors for Substance Use Disorders
Risk Factors |
Domain |
Protective Factors |
Early Aggressive Behavior |
Individual |
Impulse Control |
Lack of Parental Supervision |
Family |
Parental Monitoring |
Substance Abuse |
Peer |
Academic Competence |
Drug Availability |
School |
Antidrug Use Policies |
Poverty |
Community |
Strong Neighborhood Attachment |
One way to understand risk and protective factors, essential in preventing drug abuse, is by the domain they affect.
Let’s go back to the life of Billie Holiday. Is there a risk factor she did not have? Is there a blessed protective factor she enjoyed, in any or all of these domains? She didn’t stand a chance: she was dead at forty-four, along the way having been a high “user” of health-care and correctional facilities, with their attendant costs.
In an interview, I was once asked, “If you could wave a wand and do one thing that would make a world of future difference for youth and their physical, mental, and addictive health, and the avoidance of time spent in jails and prisons, what would that be?” My mind did not go to some great scientific discovery, as welcome as that would be, but rather to what was destroying the health and welfare of so many children and adolescents now, and where action could be taken today.
My answer was to eliminate ACEs. ACEs are “adverse childhood experiences,” which can usher in a lifetime of misfortune—and frequently then pass troubles on to succeeding generations. These are events beyond young people’s control. Through no choice of their own these youth are subject to powerful stressors that adversely impact their minds and bodies.
The principal types of ACEs are abuse, neglect, and seriously troubled households. Specifically, ACEs include emotional, physical, and sexual abuse; emotional and physical neglect; and homes that have domestic violence, mental and/or substance use disorders, parental separation or divorce; or a family member who is incarcerated. ACEs occur before a child reaches the age of eighteen—but their effects are painfully enduring.
* * *
Luisa Gomez, age fourteen, who lives with her grandmother in Spanish Harlem, is pregnant and failing in school. She is obese, smokes, and is showing metabolic evidence of insulin insensitivity, a precursor to adult-onset diabetes. She has been diagnosed with depression and has already taken an overdose of tranquilizers after a disappointment with her boyfriend, using pills she found in a friend’s bathroom cabinet. She was raised in a series of foster homes from age five until eleven, placed there after she was sexually abused by her stepfather and because her mother, addicted to crack cocaine, was unable to care for her. Her father had abandoned her mother shortly after Luisa was born. Her grandmother is infirm, and Luisa takes more care of her than the grandmother does of Luisa. Her pregnancy was the result of unprotected sex and the underlying need to prove that she was desirable to boys. It is unclear who is the father of Luisa’s child. Her future looks dismal, with few skills, limited education, minimal adult support, and a body and mind already suffering from the consequences of a host of adverse childhood experiences.
Sadly, there are many Luisas (and their male counterparts) throughout our country. Their suffering and burden to society are vast, likely unmeasurable.
* * *
What is so troubling about ACEs is that they are additive. One is bad enough, but four, five, or more are a powerful prescription for illness and despair, often by adolescence. ACEs can lead youth in this or any other country to such problems, among many others, as alcohol and drug abuse; depression; heart, lung, and liver diseases; STDs; intimate-partner violence; smoking, especially at an early age; suicide attempts; and unintended pregnancies. As the number of ACEs youth experience increases, so too does their risk for multiple consequences.
ACEs seem to do their damage in two principal ways: first, by inducing a chronic stress response in the brain, and thus body, which lowers immunity to disease and is instrumental in the development of a variety of mental and physical illnesses such as depression and PTSD—as well as limiting the capacity to recover from them. Second, they also do damage in the long term, producing effects such as cigarette smoking, alcohol and drug abuse, and unprotected sex. The combined results of chronic stress and risky behaviors induce a host of diseases and social problems, often by adolescence or young adulthood. Diseases and disorders mount, limiting functioning and quality of life and producing disability and early death.
It is because of the prevalence of ACEs and because of their impact on our youth that I answered the interviewer’s question the way I did.
Prevention of ACEs is no small feat. But there are ways to make a difference, now. And the payoff might even exceed the return on investment seen in California’s anti-tobacco campaign. Frederick Douglass said, “It is easier to build strong children than to repair broken men.”
A couple examples of proven approaches to ACEs and childhood trauma and behavioral problems come to mind.
The first step must be prevention of the consequences of childhood abuse, neglect, and troubled homes, which remains elusive despite its importance. I asked Laurie Miller Brotman, PhD, a colleague at NYU and a friend, to give us an example of how a family beset with adverse childhood experiences was helped by ParentCorps, her community-based intervention that is delivered as an enhancement to pre-K programs.
* * *
Graciela is a married woman in her early forties who has struggled with anxiety since immigrating to New York as a teenager. She experienced both sexual harassment in her factory job and severe postpartum depression after the birth of Jaden, her only child. Jaden was four years old when a teacher at his pre-K program told his mom about ParentCorps. Graciela struggled to respond to Jaden’s behavior at home and was afraid to tell anyone how out of control she felt. She felt isolated and was sure she was failing as a mother.
The social worker at the pre-K program helped Graciela garner the courage to walk through the door of the first of fourteen conveniently scheduled ParentCorps sessions. She was hesitant and unsure if it would be helpful. She had tried everything she could think of to calm Jaden and prevent his tantrums and screaming.
She was surprised when the ParentCorps facilitator, the same trusted social worker who’d brought her there, talked with her and the other parents about their lives, what they valued, and their goals for their children. Graciela was asked to think about her own upbringing—what she wanted to repeat as a mother and what she wanted to leave behind.
The most powerful experience for Graciela was hearing from other parents about their own struggles, as well as learning what behaviors were “normal” for four-year-olds. She was scared about her son and how often she and her husband fought about how to respond to him. But she came to feel safe at the meetings with the other parents; she was eager to learn about how to create routines such as helping Jaden go to bed on time and stay in his own bed all night. She also learned how to help her son cope with frustration and anger.
As Graciela went home each week and put her new knowledge into practice, she began to see results. Her son’s behavior improved rapidly. Within a few weeks, and with additional support from the social worker, Jaden’s tantrums ceased altogether. He began sleeping in his own bed all night, a huge accomplishment and a relief to his parents. These parenting successes with Jaden had ripple effects throughout the family, easing tension between Graciela and her husband and reducing Graciela’s anxiety. She started to trust her instincts as a mother and experimented with ways to bring the concepts she was learning to other parts of her life.
Brotman and her team at the Center for Early Childhood Health and Development are partnering with the NYC Division of Early Childhood Education to bring ParentCorps to fifty pre-K programs and have plans to help families create safe, nurturing, and predictable environments in the classroom and at home in three hundred additional programs. All told, their 1,850 programs serve seventy thousand children annually.
* * *
A second example is the enduring program Big Brothers Big Sisters, operating since 1904. Their tagline is “Millions of children need a caring adult role model,” which seems to me to be a modest underestimate. Their theory of change is that the regular presence of a caring adult is a powerful antidote to youth engaging in risky, even dangerous, behaviors, and to keeping their focus on school and healthy relationships.
Big Brothers Big Sisters seeks out youth at risk: those living in foster care, in dangerous neighborhoods, and in homes riddled with domestic violence or drug use, and these already having encounters with the juvenile justice system. These are kids apt to be swallowed up by the chaos and destruction of the environments they live in, through no choice of their own. The youth are not only attached to their big brother or sister, but are also exposed to art, music, sports, education, and community organizations where contribution is the prevailing ethos for them to learn.
These are but two of many examples of how prevention and early intervention can keep so many youth from lives of disruption, addiction, incarceration, and despair.
Other wonderful examples include home visits to first-time moms by nurses; programs such as Positive Parenting and the Incredible Years; as well as pediatric and primary-care screening and early intervention for depression and substance use problems in youth; and trauma-focused treatment programs for youth already showing problems. We have alternatives, but so far their adoption is terribly limited.
Again, consider Billie Holiday. Her mother was addicted to narcotics, her father missing. As a youth, her community was a brothel. Violence pummeled her, from rape at age ten to ongoing abuse by her pimp-husband. She was jailed, sent to reform school, and punished. By the time she was an adolescent she was homeless, drinking heavily, and en route to a heroin habit.
But not all those subject to ACEs draw such a profoundly miserable deal. Even for those who do, children and adolescents with a decent measure of resilience, self-control, and support can change the trajectory of their lives—but the odds at first are against them. They need help, as do their families.
Returning to the nosology of universal, selected, and indicated aspects of prevention, with a focus on adolescence, there are many ways to facilitate change, though they are not as often employed as they could be.
On a universal level, a fine and demonstrably effective example is LifeSkills Training (LST). LST curricula are available for elementary schools (grades three to six); middle or junior high schools (grades six to eight or seven to nine); and high schools (grades nine or ten). For example, LST can be delivered for three years in middle schools. Students are taught essential, usually previously underdeveloped skills, such as problem solving and decision making, which help these youth resist peers and media encouraging drug use—also called drug-resistance skills—as well as coping mechanisms and methods to manage stress and anxiety. Self-esteem and self-control typically improve. LST shows sustained effects with preventing tobacco, alcohol, and marijuana use as well as binge drinking.
Another universal approach is exemplified by the family-based Strengthening Families Program: For Parents and Youth 10–14. Provided in rural areas, this program helps parents build the skills to manage a family, communicate in positive ways, improve relationships with their children, and support academic and extracurricular activities. There is considerable flexibility in where and when services are delivered, and babysitting, transportation, and meals help with engagement and ongoing family participation.
A selective-level intervention for high-risk schools and youth is the Project Towards No Drug Abuse (TND), though it has also spread to some schools and students not clearly at risk—unless we consider all school youth at risk, which has some face validity. In working with students fourteen to nineteen years of age, the goal is to help them resist substance use. TND is delivered in twelve forty-to-fifty-minute lessons; it too teaches social skills and decision making, as well as aiming to improve student motivation to stay clean. There are group discussions, role-playing exercises, and videos.
An example of an indicated approach is the Brief Alcohol Screening and Intervention for College Students (BASICS) program. BASICS is directed toward college students already showing evidence of heavy drinking, and who are at risk for alcohol-related problems such as accidents, poor class attendance, failure to meet deadlines on assignments, sexual assault, and violent behavior. BASICS, done in two one-hour meetings with an online assessment between the two, seeks to help students reduce alcohol consumption and thereby decrease its consequences.
The time is right, as well, for introducing and broadly disseminating Screening, Brief Intervention, and Referral to Treatment (SBIRT) for youth. This can be done at universal (primary-care/pediatric), selective (school- and community-program), and indicated (emergency-room and juvenile-justice) levels. SBIRT for some, but not all, affected youth is becoming an essential element of behavioral health–care services in general-, primary-, and family-medicine practices. Teenagers at risk or showing evidence of alcohol and drug abuse—for instance, accidents, missing school or failing in class, risky behaviors, trouble with the law, worrisome changes in friend groups, frequent medical problems without a clear physical condition—in pediatric, primary-care, or emergency services are asked as few as two questions. The first question is about friends’ drinking, an early-warning sign that is highly associated with the youth’s current or future substance use and is often more effective than asking the youth directly about himself. The second question is about the youth him- or herself, directly inquiring about frequency of substance use.
The American Academy of Pediatrics, in 2011, recommended substance screening as a “routine” part of adolescent health care.
SBIRT has varied approaches for youth ages nine to eleven, eleven to fourteen, and fourteen to eighteen (where the patient question is asked before the question about friends). It is a good example of secondary prevention, that is, the detection and treatment of a condition before it advances and becomes more fixed. While some youth respond to the primary-care doctor’s concern and counseling, others do not and will require “referral to treatment,” the last part of SBIRT’s name. Some physicians are reluctant to adopt SBIRT because they worry about their capacity to adequately refer their patients. Shortages of substance use disorder services can be legion, particularly when crossing the chasm from a medical-care setting to behavioral health care. There’s also the problem of both sites getting adequately reimbursed, the federal Parity Act and its Health and Human Services regulations notwithstanding. The concern of these doctors adds more voices to the call for greater access to and coverage of quality care for youth (and adults) experiencing every level of problems with alcohol and drugs.
I would be remiss not to touch on community-based approaches to prevention. As a rule, the more of these mobilized, the more effective their collective impact—in academic, family, and also community settings. Community approaches also include media campaigns and community organizations (such as the Y, Big Brothers Big Sisters, and local gyms), as well as faith-based settings and programs. Public-policy initiatives can also be community based, such as sanctions for servers who sell alcohol to minors, regulations to limit the number of bars and liquor stores, and aggressive sobriety stops for drivers.
A great many other examples of prevention of alcohol and drug problems exist. As with other sections in this book, I am offering illustrations—not a textbook or an encyclopedia of materials. I hope I have begun to show how much has been done, and just how much work remains.
A set of critical principles underlie public-health approaches to prevention. In considering and selecting from available methods, it is useful to see if any given prevention approach meets the recognized principles that forecast success. They include:
• Family, school, primary-care, or community-serving locations
• Early screening and detection
• Identifying and intervening with the social determinants of addiction (e.g., ACEs)
• The prominent use, for adolescents, of peers
• Ready access to equitable, affordable, effective, comprehensive treatment
• Relentless use of data to measure the problem(s) selected, to monitor the effectiveness of efforts, and to check for continuous quality improvement
• The capacity of a program to “scale up,” or become commonly present throughout an area
• Insistent demand for adoption of policies that capture savings (from health care, social welfare, and corrections) and use of those savings to further invest in prevention and treatment
I hope no one thinks that after all my years of developing, implementing, and running services, clinically and governmentally, that I imagine that delivering on a prevention agenda is easy. It most certainly is not. But if the Wright brothers, Jonas Salk, Watson and Crick, Marie Curie, Nelson Mandela, Martin Luther King, and countless others had been cowed by complexity and resistance, we would still want for their discoveries and the impact they have had on society.