Brian R. Flay, D.Phil., Professor Department of Public Health Oregon State University

1. Causes and Prevention of Multiple Problem Behaviors: The Theory of Triadic Influenceand its Applications Brian R. Flay, D.Phil., Professor Department of Public Health Oregon State University Presentation for H699, January 2010

2. Proximal Correlates of Behavior Attitudes Toward Behavior Self-Efficacy Social Normative Beliefs Intentions/Decision BEHAVIOR Social skills Self management Self-efficacy Social Norms theories Conformity theories Expectancy theories Attitude theories 2

3. Distal Causes of Behavior Intentions/Decision BEHAVIOR Biological theories Psychoanalytic theories Resilience (Garmazey) Personality theories Self-Control (Gottfredson & Hirschi) Social Control (Elliott) Family Systems (Brooks) Peer Clustering (Oetting) Class Conflict Low SES, Anomie Social Disorganization Strain Theory (Merton) Radical Theories GENETICS ENVIRONMENT IntraPersonal Environment Social Situation 3

4. A Matrix of Theories(Petraitis, Flay & Miller, Psychological Bulletin, 1995) Note: Some of these theories cross cells, particularly the sociological theories. Some explicitly integrative theories cross many cells (e.g., Brooks, Elliott, Jessor). 4

5. THE THEORY OF TRIADIC INFLUENCE ENVIRONMENT GENETICS IntraPersonal Environment Social Situation Attitudes Toward Behavior Self-Efficacy Social Normative Beliefs Intentions/Decision BEHAVIOR 5

6. THE THEORY OF TRIADIC INFLUENCE CULTURAL SOCIAL BIOLOGY/ ENVIRONMENT SITUATION PERSONALITY ATTITUDES SOCIAL SELF-EFFICACY TOWARD THE NORMATIVE BEHAVIORAL BEHAVIOR BELIEFS CONTROL Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream Biological/Nature Nurture/Cultural DECISIONS/INTENTIONS Trial Behavior EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological 6

7. THE THEORY OF TRIADIC INFLUENCE Levels of Causation Ultimate CULTURAL SOCIAL BIOLOGY/ Causes ENVIRONMENT SITUATION PERSONALITY Social/ Personal Nexus Interactions w/ Social Instit’s Distal Influences Expectancies & Evaluations ATTITUDES SOCIAL SELF-EFFICACY Affect and Cognitions TOWARD THE NORMATIVE BEHAVIORAL BEHAVIOR BELIEFS CONTROL Proximal 19 20 21 Predictors Decisions 22 Experiences 23 Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream Biological/Nature Nurture/Cultural 1 2 3 4 5 6 Sense of Information/ Interpersonal Others’ Social Self/Control Opportunities Bonding Beh & Atts Competence 7 8 9 10 11 12 Self Skills: Motivation Perceived Values/ Knowledge/ Determination Social+General to Comply Norms Evaluations Expectancies 13 14 15 16 17 18 DECISIONS/INTENTIONS Trial Behavior EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological 7

8. THE THEORY OF TRIADIC INFLUENCE Levels of Causation Ultimate CULTURAL SOCIAL BIOLOGY/ Causes ENVIRONMENT SITUATION PERSONALITY a f Social/ Personal Nexus c d e b Interactions w/ Social Instit’s Distal Influences Expectancies & Evaluations s x ATTITUDES SOCIAL SELF-EFFICACY u w v t Affect and Cognitions TOWARD THE NORMATIVE BEHAVIORAL BEHAVIOR BELIEFS CONTROL Proximal 19 20 21 Predictors Decisions 22 Experiences 23 Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream Biological/Nature Nurture/Cultural 1 2 3 4 5 6 Sense of Information/ Interpersonal Others’ Social Self/Control Opportunities Bonding Beh & Atts Competence 7 8 9 10 11 12 g r p i q h k n m l j o Self Skills: Motivation Perceived Values/ Knowledge/ Determination Social+General to Comply Norms Evaluations Expectancies 13 14 15 16 17 18 DECISIONS/INTENTIONS Trial Behavior EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological 8

9. THE THEORY OF TRIADIC INFLUENCE Levels of Causation Ultimate CULTURAL SOCIAL BIOLOGY/ Causes ENVIRONMENT SITUATION PERSONALITY 1 2 3 4 5 6 a f Social/ Personal Nexus c d e b Sense of Information/ Interpersonal Others’ Social Interactions w/ Self/Control Opportunities Bonding Beh & Atts Competence Social Instit’s Distal Influences 7 8 9 10 11 12 g r p i q h k n m l j o Expectancies & Evaluations Self Skills: Motivation Perceived Values/ Knowledge/ Determination Social+General to Comply Norms Evaluations Expectancies 13 14 15 16 17 18 s x ATTITUDES SOCIAL SELF-EFFICACY u w v t Affect and Cognitions TOWARD THE NORMATIVE BEHAVIORAL BEHAVIOR BELIEFS CONTROL Proximal 19 20 21 Predictors Decisions A G B H C I D E F 22 Experiences 23 Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream Biological/Nature Nurture/Cultural DECISIONS/INTENTIONS Trial Behavior EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological 9

10. THE THEORY OF TRIADIC INFLUENCE Levels of Causation Ultimate CULTURAL SOCIAL BIOLOGY/ Causes ENVIRONMENT SITUATION PERSONALITY 1 2 3 4 5 6 a f Social/ Personal Nexus c d e b Sense of Information/ Interpersonal Others’ Social Interactions w/ Self/Control Opportunities Bonding Beh & Atts Competence Social Instit’s Distal Influences 7 8 9 10 11 12 g r p i q h k n m l j o Expectancies & Evaluations Self Skills: Motivation Perceived Values/ Knowledge/ Determination Social+General to Comply Norms Evaluations Expectancies 13 14 15 16 17 18 s x ATTITUDES SOCIAL SELF-EFFICACY u w v t Affect and Cognitions TOWARD THE NORMATIVE BEHAVIORAL BEHAVIOR BELIEFS CONTROL Proximal 19 20 21 Predictors Decisions A G B H C I D E F 22 K Experiences 23 Related Behaviors J Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream Biological/Nature Nurture/Cultural DECISIONS/INTENTIONS Trial Behavior EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological 10

11. THE BASICS OF THE THEORY OF TRIADIC INFLUENCE THE BASICS OF THE THEORY OF TRIADIC INFLUENCE DNA Social Competence Biology Social & Personality Skills Sense of Self SELF Self Determin- EFFICACY ation Decisions/ Intentions Others' Perceived Beh&&Atts Norms SOCIAL Social NORMATIVE Context BEHAVIOR BELIEFS Motivation Bonding to Comply Values ATTITUDES Values Evaluations Evaluations Culture Knowledge Religion Cultural Expectancies Environment Environment Informational Environment 11

12. The TTI Developmental-Ecological System ENVIRONMENT Situation E E Person P P S S Values Environment Knowledge Environment P S E Value Social Bonds Role Models Know Self- Control Com- petence Cognitive/Competence Substreams Affective/Control Substreams Exp Eval Mc NB Will + Skill Att Att SNB Self Efficacy SNB Intentions Behavior Levels of Causation Ultimate Underlying Causes Distal Predisposing Influences Proximal Immediate Predictors DEVELOPMENT & TIME 12

13. THE THEORY OF TRIADIC INFLUENCEImplications for Description and ExplanationSystem Postulates 1 & 2 1. Provides a meta-theoretical view • Higher order description and explanation • Integrates multiple levels of organization • No one existing theory can provide a satisfactory description • Certainly, no one variable can provide an adequate explanation 2. Each behavioral choice is influenced by a complex system of PERSONAL,SOCIAL and ENVIRONMENTAL factors 13

14. THE THEORY OF TRIADIC INFLUENCESystem Postulates 3 & 4: • 3. All three (triadic) streams of influence each have two substreams (making 6 altogether): • 3 informative/cognitive/thoughts substreams • 3 control/affective/feelings substreams • 4. All (sub)streams of influence flow from causes most distant (ultimate and distal) to causes closest to (proximal to) the behavior of interest -- a cascade of multiple and interacting influences • Proximal causes predict most behavior • Distal and ultimate causes help explain it 14

15. THE THEORY OF TRIADIC INFLUENCESystem Postulates 8 & 9: • 8. Once a behavior occurs, the resulting reactions and/or experiences (thoughts and feelings) feed back to change the original causes • E.g., engaging in a behavior changes one’s self-efficacy, relationships with parents and peers, and attitudes • 9. Feedback changes the likelihood of engaging in the same or a similar behavior in the future • Thus, causes and effects are in a continuous cycle: • With each behavior changing the causes, and • The changed causes leading to the same or similar behavior over time • Mutually influential individual  contextual relations • Developmental regulation 15

16. THE THEORY OF TRIADIC INFLUENCESystem Postulates 10: • 10. The reactions to certain behaviors feed back to influence the causes of related behaviors • e.g., smoking and other drug use • - Related behaviorshave similar causes, with the more distal causes being the most similar • - Less related behaviors (e.g., smoking and skiing) have fewer causes in common • - Even related behaviors have some differences in proximal causes 17

17. Closely and less related behaviors: Ultimate causes may be the same, distal predictors less so. P P P P P P P S S E S S S S E E E E E E S A Two Less and single closely less related behavior related behaviors. Eg, Eg, smoking, behaviors. Eg, smoking smoking drug abuse, and drinking sex, exercise. 18

18. IMPLICATIONS OF TTIFOR BEHAVIOR CHANGE AND PREVENTION • OLD APPROACHES TO PREVENTION COULD NOT HAVE WORKED WELL • Informational approaches focus only on knowledge • Values clarification approaches focus only on values • Decision-making focuses only on the attitudinal stream • Resistance skills programs often focus only on one social skill • Only a few recent programs include changing social normative beliefs 19

19. IMPLICATIONS OF TTIFOR BEHAVIOR CHANGE AND PREVENTION • NEW INTERVENTIONS NEED TO BE BROADER, LONGER, DEEPER, ... • But should not throw out all of the content of traditional approaches • Add family participation and parenting/communication skills • Teach multiple relevant skills • Special interventions for children in high-risk families (genetics) • Consider how to impact broad sociocultural influences • reduce sales/access to minors (alcohol and tobacco) • eliminate advertising, alcohol and tobacco, billboards and TV • increase taxes on tobacco and alcohol • change school lunches • reduce exposure to violence on TV and in movies • train kids to be advocates • USE BEHAVIORAL CHANGE STRATEGIES FROM ALL SIX SUBSTREAMS 20

20. Causes, Reasons, and Strategies for Contextual and Behavioral Change 21

21. The first test of the TTI and changing multiple behaviors at once: The African American Youth Project: “ABAN AYA” • Afro-centric programming, grades 5-8 • History, culture, Kwanza values • Name means Protection + Self Determination • Targeted drug use, violence, delinquency and unsafe sex • School-based randomized trial • 4 schools per condition – 3 arms • Social Development Curriculum (SDC) vs School + Community (SC) vs control (Health Enhancement Curriculum - HEC) • Program development informed by the TTI • Dose-response effectiveness on multiple behaviors (Archives of Pediatric & Adolescent Medicine, 04) • Multiple papers on moderation and mediators 22

22. AAYP Programs Developed and Tested • Social Development Curriculum (SDC) • Development of pro-social behavioral skills, including problem solving (and decision-making), personal relationships (including safe sex or abstinence), conflict resolution (and non-violence), and remaining drug free. • Intensive School/Community Program (S/C) • All of the above plus parent involvement, school environment changes, and community involvement. • Health Enhancement Curriculum (HEC) • Focused on exercise, nutrition and oral health. 23

23. AAYP 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

24. AAYP Intensive School/Community Intervention • 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 25

25. Mapping of ABAN AYA onto the TTI Social Service Coordination Mentoring School-wide changes Parent effectiveness training Media literacy Community, Etc. Identification of African-American role models/heroes African-American Identity & Sense of Self African-American History & Values Information/ Opportunities Sense of Self/Control Social Competence Interpersonal Bonding Others’ Behs & Atts Interactions w. Social Instit’s Values Education, Goal setting Self-control & Anger management Alternatives, Information & Consequences Norms awareness & clarification Social & Self- management Skill Building Attachment Empathy Self Determination Skills: Social+General Motivation to Comply Perceived Norms Values/ Evaluations Knowledge/ Expectancies Self-Efficacy, Behavioral Control Attitudes Toward The Behavior Social Normative Beliefs Decision-making and Problem-solving skills Decisions/Intentions Behavior 26

26. Classroom Strategies of Effective Prevention Programs OVERALL PHILOSOPHY Developmental and spiral Culturally appropriate (Afrocentric) Behavioral skills development DURATION AND INTENSITY Four years -- grades 5-8 16-20 sessions each year [+ 4-5 sessions grades 9 & 10] PARENT INVOLVEMENT Interactive homework assignments Evening presentation of "skill skits" HEALTH EDUCATOR Professional outsider (Health Educator) Socratic teaching style ACTIVITIES Question box African and AA Proverbs “Ujima” Group activities Role Play - Practice, Correction, Reinforcement Video presentations Rap music 27

27. Male substance use growth curves (logit) (Aban Aya) 28

28. Male violence growth curves by condition (Aban Aya) 29

29. Greatest effects on those most needy! (Segawa et al., 2004) 30

30. Why Positive Youth Development (PYD) or Social and Character Development? • Increasing behavioral problems in schools • Including violence, substance use, unsafe sex, and other disciplinary referrals • Seems to have worsened with increased attention to instruction for NCLB • Link of classroom behavior management to teacher time on task (teaching) • Link of student behavior to student time on task (learning) • Comprehensive education needs to address Achievement, Behavior and Character (ABCs) 31

31. Positive Action is Comprehensive Multiple Levels: Classroom curriculum Teacher training School-wide climate Family Community Multiple Domains Character education Social & emotional learning Prevention program Academic achievement • Multiple Outcomes: • School engagement: Attendance, Truancy • Behaviors: Violence, Substance use, Sexual behaviors • School-level indicators: Disciplinary referrals, Suspensions • Achievement: Grades, Standardized test scores 32

32. Basic Philosophy (Theory of Action) of the Positive Action Program & Circle You feel good about yourself when you do positive actions.C.f., Cognitive Behavior Therapy and Positive Psychology You feel bad about yourself when you do negative actions. C.f. Depression 33

33. The Positive Action Program Targets Multiple Behaviors • By teaching that: • When you do good, you feel good • And there’s always a positive way of doing things • AND • By teaching the positive actions that help: • Individuals, families, schools and communities develop positive self identities. 34

34. 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 (the Thoughts-Actions-Feelings Circle). • Unit 2. Physical and Intellectual Positive Actions for Body & 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 and Social-Emotional Learning) • 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 35

35. 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 36

36. Elementary Curriculum Kits Grades K–6 • 140 15-minute lessons • Role-playing, Plays, Stories, Questions, Poetry, Games • Student activity booklets/sheets and materials for 30 students • Hands-on activities • Puppets, flannel board characters, games • Role-playing, stories,questions, plays • Posters, music, and stickers Grade 1 Instructor’s Kit 37

37. Other Program Components • Climate Development Kits • Provide site-wide change and reinforcement • Counseling Program • Counselor Kit, Lessons for individual students or small groups • Family Program • Classes, Home Kit • Community Program • Community messages and activities, civic engagement, and media messages • Focused Topic Kits • Drug education, conflict resolution Secondary Climate Development Kit Community Kit 38

38. Mapping of Positive Action content onto the TTI CLASSROOM SCHOOL FAMILY COMMUNITY Positive Action Program Components and Lessons (Exist in each Component) IntraPersonal (Individual) Social Context/ Situations Socio-Cultural Environment Genetics Biology Personality Family School Neighborhood Peers Mass Media Regulations Religion Economy Positive Role Models Feelings Empathy Self Concept Social Bonding/ Attachment Others’ Behavior & Approval General Values Information Environment Sense of Self Social Competence Values Health & Drug Info How to Treat Others Motivation To Learn Self Management Time, Energy, Talents, Money, Anger Self- Determination Social Skills Others’ Expectations Desire to Please Evaluation of Outcomes Expected Consequences Alternative Consequences Communica -tion Skills How You Like To Be Treated Conflict Resolution Social & Emotional Health Social Normative Beliefs Attitudes Toward the Behavior Self-Efficacy Thinking Skills Creativity Decision-Making Problem-Solving INTENTIONS/DECISIONS BEHAVIOR Experiences from Behavior 39

39. Logic/Theoretic Model of the Expected Effects of the Positive Action Program Program Components Immediate Outcomes Climate Development, Family Kit, Teacher/Staff Training, K–12 Instruction Curriculum, Drug Education Supplements, Community Kit, Counseling Kit * Improved relationships among school administrators, teachers, parents & community. * Improved classroom management. * Increased involvement of school with parents & community. Improved Learning Environment Expected Impact Expected Effects PA Unit Fewer Disciplinary Problems; Reduced Substance Use; Less Violence Attitudes Toward Behaviors, Social Normative Beliefs, Self-Efficacy • Improved character/self-concept • Learning/Study skills • Self-Management • Interpersonal/social skills • Self-honesty, responsibility • Goal setting, future orientation Improved Social and Character Development Improved School Attendance, Grades and Test Scores 40

40. Effects of PA found in early matched-control quasi-experimental studies • A matched-control study of elementary schools in 2 large districts (Flay, Allred & Ordway, 2001) found: • Major reductions in problem behaviors and improvements in achievement • The matched-control study was replicated by Flay & Allred (2003) in a southeastern school district with the addition of pretest data and follow-up through MS and HS. • Found similar effects at the elementary level • Relative to middle schoolswith a low % of PA graduates (<60%), middle schools with a high % of PA graduates (80-100%) reported: • Major reductions in problem behaviors and improvements in achievement • With some of these effects being larger in high-mobility schools • Strong dose-response relationship for all outcomes, with stronger effects occurring in middle schools with greater numbers of PA graduates • Relative to high schools with a low % of PA graduates (0-15%), high schools with a high % of elementary PA graduates (27-50%): • Major decreases in problem behaviors and improvements in achievement • All effects equally strong for high-mobility & minority schools • Strong dose-response relationship for all outcomes 41

41. Hawai`i and Chicago School-based RCTs of Positive Action • Funded by NIDA & IES • Investigators • Flay, Allred (PAI), DuBois (UIC) • OSU -- Acock, Vuchinich • Multiple Staff at each site 43

42. Design of Hawai`i and Chicago Trials • Schools randomly assigned to conditions from matched pairs • 10 per condition in Hawai`i, 7 in Chicago • Matched on Archival Data • Enrollment, stability, % free/reduced lunch, per capita family income, % special education, % low English proficiency, standardized achievement scores, absenteeism, disciplinary actions, ethnic distribution • Data collected from one or two cohorts of students (grades 1 & 2 in 2000-01 in HI, grade 3 in 2003-04 in Chicago) at baseline and annual or semi-annual posttests • Surveys of students, parents, teachers/staff, teacher ratings of student behavior and school records (achievement and behavior) • A third trial in a rural Southeastern school district involved only 4 schools per condition 44

43. In Chicago Study • IES $ required signed parental consent – 98.3% returned form, 79.7% signed yes • This trial was one of 7 sites in a multi-site study of 7 different programs • Some of the measures were multi-site – collected by a national contractor (Mathematica Policy Research – MPR) at each of the 7 sites – and not available to PIs until about a year later • Some of the measures were site-specific – specific to our evaluation of the Positive Action program – collected by UIC research staff • Data were collected at beginning and end of grades 3 and 4, and end of grade 5 45

44. Hawai`i Baseline Equivalence: 2000-01 No differences are close to being statistically significant 46

45. Baseline Equivalence on Ethnic Distribution No differences are close to being statistically significant. Sample is fairly representative of all HI schools 47

46. 48

47. Implementation Measures Ratings of Implementation Fidelity Consultation Notes, Teacher Interview Weekly Implementation Reports Unit Implementation Reports End-of-Year Survey PA Committee Roster Form PA Budget PA Expenditures Report PA Committee Meeting Report Form PA School Activity Form End-of-Year Implementation Survey PA Research Team Classroom Teachers PA School Coordinators PA Budget and Expenditures Report End-of-Year Implementation Survey Principal PA Committee Members PA Committee Meeting Attendance Log and Report Form Any School Staff Person Students Student Survey PA Program Observation Form 49

48. Hawaii: Teacher Report Avg. # Lessons/wk 50

49. Chicago: Program Implementation by Year 51

50. Effects of PA on positive behaviors: Results from 3 RCTs (Washburn et al.) 52