FROM PREVENTION TO TREATMENT- FINDING THE RIGHT SETTING FOR THE RIGHT GROUP

1. FROM PREVENTION TO TREATMENT- FINDING THE RIGHT SETTING FOR THE RIGHT GROUP TARGETING MENTAL HEALTH - WORKING IN AND WITH FAMILIES EMCDDA conference May, 2009 Ana Melo Doctoral Scholar of the Foundation for Science and Technology (SFRH / BD / 39912 / 2007) E-mail: anamelopsi@gmail.com

2. WHAT DO WE KNOW ABOUT WHAT WORKS? What do we know about the role of family variables in the interplay of transactions between children’s/youth’s ontological development and eco-systemic influences?

3. WHAT DO WE KNOW ABOUT WHAT WORKS? Truancy Healthy development Psychopathology Macrosystem influences Drug misuse Exosystem influences Adolescent pregnancy Delinquency Family and parental influences ??? ontological development Contributions from developmental psychopathology: (Cummings, Davies & Campbell, 2000; Cicchetti & Lynch, 1995) Gardner, Brounstein, & Stone, 2001; Glantz & Lechner, 2000) Principles of equifinality and multifinality, along with the cumulative and interactive nature of risk and protective factors remind us of the complexity and relative unpredictability of children’s/youth’s outcomes and how different problems may relate or emerge out of different or similar initial conditions in regard to risk and protective factors. We are always working on probabilities and there is a lot we don’t know… Still…we now know that:

4. WHAT DO WE KNOW ABOUT WHAT WORKS? • Different problems share common covariates and tend to be related • The microsystem, parent and family variables are the closest source of influence • A set of family variables have been associated with diverse problems and have been found to be present in the main pathways that lead to substance abuse and other youth problems (Bry et al., 1998; Ary et al., 1999; Kumpfer, Alvarado & Whiteside, 2003; Oxford et al., 2000; Turner et al., 1998) • Research has informed program development in regard to the risk and protective factors to be targeted

5. WHAT DO WE KNOW ABOUT WHAT WORKS? • Resilience research has provided important information not only about family variables that contribute to children’s and youth’s positive development in face of adversity (Masten, 2007, Masten & Reed, 2005), but also the importance of family resilience processes in the way families overcome and grow through adversity (Walsh, 1996; 2006) • Implications in the evolution from a problem-focused to a strength and resilience-based programs and promotion of positive children/youth development and family growth

6. WHAT DO WE KNOW ABOUT WHAT WORKS? What do we know about the efficacy of family-based programs?

7. WHAT DO WE KNOW ABOUT WHAT WORKS? While there are still many limitations in current state-of-art knowledge, mainly related to problems in research design, family-based prevention programs show promising results in the prevention of several children/youth disorders and problems (Tolan, 2002; Bunting, 2004; Barlow et al., 1999; gates et al., 2006; Lochman, 2000; Barlow & Parsons, 2004; Petrie, 2007; Foxcroft et al., 2003). Family-based programs may show an efficacy up to nine times superior to child/youth focused programs, and programs that include both parent, family and children sessions show better results than programs that include only parents (Tobler & Kumpfer, 2000; Kumpfer, Alvarado &Whiteside, 2003)

8. WHAT DO WE KNOW ABOUT WHAT WORKS? What do we know about the characteristics of programs that work?

9. WHAT DO WE KNOW ABOUT WHAT WORKS? • Many programs in the field of mental health, drug abuse prevention, child maltreatment, etc. share similar components in regard to the family variables targeted since • DIFFERENT TYPE OF PROBLEMS CAN BE TARGETED AND PREVENTED THROUGH A FOCUS ON FAMILY AND PARENTAL INFLUENCES • Prevention programs evaluation has contributed to current knowledge about the importance of family variables in the prevention of child adjustment and psychosocial problems including substance abuse (Velleman et al., 2005; Masten, 2007) and provided an opportunity to test etiological theories (Luthar et al., 2000) • We may now talk of programs with evidence-based content

10. WHAT DO WE KNOW ABOUT WHAT WORKS? Programs with evidence-based content target variables as (Ary et al., 1999; Biglan & Taylor, 2000; Bry, 1998; Velleman et al., 2005; Kumpfer, et al., 1999, 2003; Kumpfer & Alvarado, 2003; Masten & Reed, 2005; NIDA, 2003) - Parents: - Responsiveness, warmth - Parental affect and positive attention - Parent-child positive interactions - Positive discipline - Monitoring and supervision - Parental modeling - etc. (for very high risk families, programs should target other social and contextual variables that influence parenting)

11. WHAT DO WE KNOW ABOUT WHAT WORKS? Programs with evidence-based content target variables as (Ary et al., 1999; Biglan & Taylor, 2000; Bry, 1998; Velleman et al., 2005; Kumpfer, et al., 1999, 2003; Kumpfer & Alvarado, 2003; Masten & Reed, 2005; NIDA, 2003) - Family: - Communication - Cohesion - Bonding - Problem-solving and conflict resolution - Emotional climate - Organization - Rules and roles -Other resilience processes (ex: positive outlook; perception of family strength, optimism, positive humor, etc.) - etc. Programs can also target children with a focus on personal and social skills.

12. WHAT DO WE KNOW ABOUT WHAT WORKS? Evidence-based family programs tend to share common characteristics (Dusenbury, 2000; Gardner, Brounstein & Winner, 2001; Kumpfer & Alvarado, 2003) • Comprehensive and multi-component • Focused on family strengths and resilience processes • Focused on relationship quality improvement • Adequate dosage - high dosages for high risk families (25-50 hours) • Age and developmentally appropriate • Address family life cycle transitions • Early beginning • Culturally adapted • Use recruitment and retention enhancement strategies • Have well trained and supervised staff • Use interactive, attractive and diverse methodologies • Empower families

13. WHAT DO WE KNOW ABOUT WHAT WORKS? What do we know about the involvement of families in prevention programs?

14. WHAT DO WE KNOW ABOUT WHAT WORKS? Many difficulties in recruitment and retention, particularly of high-risk families have been reported (Díaz, et al., 2006; Dumka et al., 1997; Biglan & Metzler, 1999; Spoth & Redmon, 2000) • However… • Many different strategies have been proposed as effective means of improving recruitment and retention rates, by eliminating barriers, such as: • (Snell-Johns, Mendez, & Smith, 2004; Cunningham & Hengeller, 1999; Dumka et al., 1997; Santisteban et al., 1996) • Positive program “marketing” in the community; • Adequate schedules (ex: end of working day) • Provision of meal and transportation; • Attractive materials • Rewards and small gifts for children • Inclusion of children components/sessions in the programs • Addressing parents’ individual needs • Offer free home services • Telephone calls and kind reminders • Staff warmth and respect, creativity and good relationship skills • Focusing on family strengths

15. IN WHICH AREAS HAS PROGRESS BEEN MADE RECENTLY AND HOW CAN PRACTICE BE FURTHER DEVELOPED?

16. PROGRESS AND FUTURE DIRECTIONS • We now have standards of efficacy and efficiency to guide research and practice (Flay et al., 2005) • A great number family-based prevention, particularly universal and selective programs have shown evidence or promise of evidence, and they are available for dissemination (Structured and manualized selective programs, in conditions to be disseminated, are not as widespread and less systematic evaluation research is dedicated to them) • Practitioners’ need to be able to assess information on evidence-based programs, but also to make sense of evidence information (Biglan & Taylor, 2000; Kellam & Langevin, 2003)

17. PROGRESS AND FUTURE DIRECTIONS • Europe is still importing more than producing or exporting family-based prevention programs. Questions need to be addressed in regard to the suitability, cultural adaptation processes and evaluation of the programs adapted to a different population (Kumpfer et al., 2008; Castro et al., 2004). • More research is needed to understand the factors that inhibit real-world implementation with fidelity of evidence-based programs (practitioners tend to alter and make changes to the programs that compromise their results) and take appropriate action (Lochman, 2000; Biglan & Taylor, 2000; Castro et al. 2004)

18. PROGRESS AND FUTURE DIRECTIONS • Practitioners’ need to be able to integrate policy and research concerns in regard to the most pressing problems and problem prevalence rate at a population-level of analysis and, at the same time, be able to adequately address the needs of the specific groups of families they encounter. More support is needed for the development and dissemination of assessment instruments that allow practitioners to accurately respond to the level and nature of risk presented by a family as well as its specific needs with the best available evidence (Schwalbe, 2008; Sackett et al., 2000, cit. in Scholsky & Wagner, 2005) • Practitioners need more support, training and instruments that help them to effectively distinguish between cases suitable for selective or indicated prevention (and for which type of program), and to combine different interventions that target different variables

19. PROGRESS AND FUTURE DIRECTIONS • Funding should cover expenses associated with recruitment and retention strategies and incentives should be provided for the involvement of different community agents in guaranteeing the removal of obstacles that inhibit family involvement and attendance • Global and local social marketing should be improved and intensified in order to create a positive supporting culture for family-based programs, with a greater shared value attributed to the preventive power of family well-being and growth

20. HOW CAN WE KEEP UP-TO-DATE WITH PROGRESS IN INTERVENTION PRACTICE APPLIED IN REAL WORLD SETTINGS?

21. PROGRESS AND FUTURE DIRECTIONS • Monitoring activities should be organized at different levels, allowing for a better identification of the quality of different family-based programs both globally and locally (Hoagwood, 2005) • Strategies for data collection should be reconsidered to ensure that information from small local, but possibly effective projects and practices is considered

22. PROGRESS AND FUTURE DIRECTIONS More family-based prevention is probably being done (or could be done) than one might think at first: • Family-based prevention is probably disseminated in several areas if we realize how many variables, themes, strategies and even programs can be used in different fields and contexts of action (social welfare, child protection, drug abuse, schools) to prevent several different problems (child maltreatment, psychopathology, drug use, delinquency, etc.), or promote mental health. • This means that programs that are being implemented with the purpose of preventing a different problem may, in fact, due to the family focus, be also preventing drug use, even though the data produced are not being used to evaluate the program with this purpose. …

23. PROGRESS AND FUTURE DIRECTIONS … • Short standardized assessment protocols could be made available for local organizations implementing family-based prevention programs, independently of their assumed purpose • Partnerships with universities could be promoted to gather data from these small scale program implementation in order to inform research and practice improvement • Policy should take in consideration the need for an integrated approach in regard to assessment of families’ needs and prevention and intervention strategies and programs (Department of Health, 2000) • Family centres should be provided with adequate support and incentive to develop a broad range of family services that respond in an integrated way to families with different needs while addressing population-level orientated concerns in regard to the most pressing problems (ex: drug use, child maltreatment) with the best available-evidence (Warren-Adamson, 2006)

24. The main strengths, talents and competencies that foster a happy, positive and healthy life emerge not only from ourselves but, above all, from between the spaces that connect people and from what together we can achieve. For prevention efforts to succeed we must continue to understand and support families’ positive development and strengthening.

25. Thank you for your attention!