Anthony Biglan

Development of Adolescent Problem Behavior

The developmental model of adolescent antisocial behavior advanced by Patterson and colleagues (e.g., Patterson, Reid, & Dishion, 1992) appears to generalize the development of a diverse set of problem behaviors. Structural equation modeling methods were applied to 18-month longitudinal data from 523 adolescents. The problem behavior construct included substance use, antisocial behavior, academic failure, and risky sexual behavior. Families with high levels of conflict were less likely to have high levels of parent–child involvement. Such family conditions resulted in less adequate parental monitoring of adolescent behavior, making associations with deviant peers more likely. Poor parental monitoring and associations with deviant peers were strong predictors of engagement in problem behavior. These constructs accounted for 46% of the variance in problem behavior. Although association with deviant peers was the most proximal social influence on problem behavior, parental monitoring and family factors (conflict and involvement) were key parenting practices that influenced this developmental process.

Behavioral Family Interventions for Improving Child-rearing: A Review of the Literature for Clinicians and Policy Makers

This paper reviews evidence that behavioral family interventions are effective at improving child-rearing in distressed families and families with children exhibiting disruptive behavior. Essential therapeutic strategies offered within a collaborative therapeutic process are identified. Exemplary materials for parents and clinicians are identified. Differences between behavioral family interventions and two popular press parenting approaches are highlighted, including the lack of empirical support for these widely used programs and the advice they offer which runs counter to behavioral approaches. Recommendations are offered for combining behavioral family interventions with other empirically supported approaches, promoting more widespread use of empirically supported treatments, such as behavioral family interventions, and the need for a public health perspective on family functioning, involving collaboration among clinicians, policy makers, and researchers.

The Value of Interrupted Time-Series Experiments for Community Intervention Research

Greater use of interrupted time-series experiments is advocated for community intervention research. Time-series designs enable the development of knowledge about the effects of community interventions and policies in circumstances in which randomized controlled trials are too expensive, premature, or simply impractical. The multiple baseline time-series design typically involves two or more communities that are repeatedly assessed, with the intervention introduced into one community at a time. It is particularly well suited to initial evaluations of community interventions and the refinement of those interventions. This paper describes the main features of multiple baseline designs and related repeated-measures time-series experiments, discusses the threats to internal validity in multiple baseline designs, and outlines techniques for statistical analyses of time-series data. Examples are given of the use of multiple baseline designs in evaluating community interventions and policy changes.

Nurse-Assisted Counseling for Smokers in Primary Care

Physician-delivered, stop-smoking interventions significantly improve quit rates among smoking patients [1-6]. Unfortunately, only about one half of physicians in nonresearch settings consistently counsel smokers [7-11], and fewer than one half of all smokers report that a physician has ever advised them to quit [12-14]. Given the pressures of routine medical practice, it is not surprising that physicians do not take 3 to 5 minutes to counsel every smoking patient they see. Tobacco counseling competes with other pressing clinical tasks; physicians are often too busy to routinely and repeatedly counsel all patients who smoke [11, 15-17]. Physicians will deliver a cessation protocol as part of a study [5, 6, 18], but barriers such as a lack of time, training, and confidence make counseling in nonresearch settings less likely [1, 4, 19, 20]. New approaches [21-23], such as involving other office staff in counseling [17, 24, 25], are needed if tobacco counseling is to become a consistent and sustainable part of medical care delivery [26]. Because physicians see roughly 70%, or 38 million, of the 53 million smokers in the United States each year [15], even a modestly effective physician-driven intervention would have considerable impact on the nations health. This study tested the feasibility and effectiveness of a team counseling approach designed to minimize the burden on physicians by using non-physician clinic staff to provide the more time-consuming parts of cessation counseling. Key features of the team approach were a brief (30-second) physician-delivered cessation message, referral to an on-site nurse or other staff for additional cessation support, and the use of videos to deliver much of the intervention in an efficient and standardized manner. A previous report of process and short-term outcome measures showed that this organized team approach proved practical and sustainable [27]. The participating physicians and other providers delivered brief advice to 86% of identified smokers during the 1-year intake period, and most patients (87%) saw the counselor for materials and additional counseling. Nurse-Assisted counseling led to significantly improved quit rates at 3 months compared with brief physician advice alone. We present the effects of the intervention on long-term abstinence at 1 year. Methods Setting We conducted our study in two large primary care facilities of Kaiser Permanente Northwest Region, a group-practice health maintenance organization (HMO) in Portland, Oregon. Receptionists asked patients between 18 and 70 years of age to complete a health habit survey while waiting for their visit. The patients were seeing 1 of 60 primary care physicians (n = 42), physician assistants (n = 7), or nurse practitioners (n = 11) in outpatient internal medicine and family practice offices. Intervention Regular clinic nurses and clinical assistants collected the surveys as patients were taken to examination rooms and attached a notice to the medical charts of smokers (n = 3161) to alert providers to deliver a brief stop-smoking advice message. Providers were oriented to their role in a 1-hour training session. They were encouraged to use their own words but to not go beyond the following basic 30-second message: The best thing you can do for your health is to stop smoking and I want to advise you to stop as soon as possible. I know it can be hard and many try several times before they finally make it. You may or may not want to stop now, but I want you to talk briefly with our health counselor, who has some tips to make stopping easier when you decide the time is right. The 2707 (86%) smokers who received the provider advice message were considered participants in the study, regardless of whether they were willing to see the counselor or had any interest in quitting smoking. By the end of follow-up, 16 patients died, leaving a total sample of 2691. At the conclusion of the physician consultation, patients were seen by an on-site project nurse or health counselor who described what would be offered and obtained verbal consent to proceed. Patients who would not see the health counselor were mailed materials appropriate to their treatment assignment. Two random digits contained in the patients health record number were used to assign patients to one of the following four interventions: advice, self-quit, group-referral, or combination treatment. Physicians remained blind to treatment assignment. Advice participants received the 30-second provider advice message and a brief pamphlet, Why Do You Smoke?, from the health counselor. This clear and systematic advice would probably be more effective than no treatment or usual care, which were not included for logistic and ethical reasons. The self-quit condition included cessation advice, a carbon monoxide assessment, and a 10-minute How to Quit Smoking video designed specifically for this population. The video focused on the need to make a personal decision to quit, the steps to successful quitting, the frequent need for repeated efforts, and the importance of setting a specific quit date and using substitutes to smoking. The counselor provided a stop-smoking kit including smoking substitutes such as gum, toothpicks, and cinnamon sticks. A choice of one of three stop-smoking manuals was offered. Most participants chose the National Cancer Institutes manual, Quit for Good (54%), although others chose Calling it Quits (17%) or a two-part workbook produced by the American Lung Association titled, Freedom from Smoking in 20 Days and A Lifetime of Freedom from Cigarettes, respectively (29%). Patients were encouraged to set a specific quit date or some other specific plan of action and the counselor arranged to call the patient, usually within 2 to 4 weeks, to check on progress toward cessation. Patients were also mailed a set of stop-smoking tip sheets and a series of six professionally designed bimonthly newsletters devoted to smoking cessation. Group-referral participants also received advice, the carbon monoxide assessment, and a video. In this case, however, the video encouraged patients to join the HMOs intensive stop-smoking group program known as Freedom from Cigarettes. This program entails nine group meetings over 2 months. In a recent study, this program achieved roughly a 35% biochemically verified 1-year quit rate [28]. Patients were provided a brochure, a schedule of group sessions, and a time-limited coupon to waive the program fee. Efforts were made to schedule the patient for an upcoming group. Reminder postcards were sent 1 week before the scheduled meeting, and patients were called several days after the meeting to check on progress and, if necessary, to reschedule. Combination participants also received advice, the carbon monoxide assessment, and a third video, which described both the self-directed and the professionally led group approaches to smoking cessation. Self-directed cessation techniques, as well as the pros and cons of joining a professionally run program, were presented. Participants were asked to choose an approach that made sense for them. The self-help manual, stop-smoking kit, group materials, and fee-waiver coupon were all provided. Participants were encouraged to either set a quit date or sign up for a specific group session, and a telephone call was arranged to check on progress. Tip sheets and the bimonthly newsletters were mailed to all combination participants. Follow-up and Analyses Participants were surveyed by mail 3 and 12 months after their initial visits. Nonresponders were interviewed by telephone by an assessor who was blind to treatment assignment. Participants reporting abstinence from tobacco for at least 7 days before the 12-month assessment were asked to schedule appointments at a convenient clinic location or at their homes to provide saliva samples for biochemical confirmation. The primary end point was a two-point prevalence measure, which was defined as consecutive abstinence at both the 3- and 12-month assessments. Nonrespondents and those lost to follow-up were considered to be smokers. Results As shown in Table 1, participants in the four treatment groups were similar in terms of baseline age, sex, race, education, occupation, cigarettes smoked per day, stage of change, confidence in ability to quit, perceived degree of overweight, and subjective health status [27]. Table 1. Baseline Characteristics by Treatment Group* Self-reported smoking status was obtained on a high percentage of participants at both the 3-month (88%) and 12-month (86%) follow-up assessments. Response rates did not differ significantly across treatment groups. The proportion of participants who reported one or more serious attempts to quit in the year following their clinic visit was significantly higher (P < 0.004) among self-quit participants (53%) relative to advice participants (46%). Group-referral (48%) and combination participants (50%) did not differ from advice participants in terms of quit attempts. All three nurse-assisted interventionsself-quit, group referral, and combinationresulted in higher 3-month point prevalence quit rates than did the advice treatment (Table 2). At the 12-month follow-up, a larger percentage of participants reported abstinence, although differences between treatment arms were reduced. The 12-month point prevalence definition of abstinence, however, includes both long-term ex-smokers and those who quit as little as 1 week before the 1-year follow-up. With the more conservative primary end point, consecutive abstinence at both the 3-month and 12-month assessments, the three nurse-assisted interventions were superior to the advice intervention. Because quit rates for the three nurse-assisted interventions were similar for all analyses (P > 0.2), they were collapsed and compared to the advice intervention. Quit rates in the nurse-assisted groups were significantly higher than advice for the 3-month (6.

Smoking onset among teens: An empirical analysis of initial situations

This study attempted to identify factors associated with smoking onset among teens. It was hypothesized that initial cigarette smoking is largely prompted by peers, and that these prompts and subsequent social reinforcement may account for smoking participation. An in-depth structured interview investigating the first three smoking or smoking pressure experiences was conducted with 157 teens, including persistent experimental smokers (who smoked more than 10 cigarettes), minimal experimental smokers (who smoked less than 10 cigarettes), and nonsmokers. Analyses confirmed that prompting by peers is characteristic of a large majority of smoking onset situations. Initial situations are much more likely to involve others of the same sex. In roughly half of the incidents another young person was trying a cigarette for the first time. Persistent experimenters, when compared with minimal experimenters, were exposed to significantly more influences to smoke. These influences included modeling and social encouragement. Additional data suggested that persistent experimenters were more primed to smoke than minimal experimenters. For example, they had engaged in more premeditation, accepted offers to smoke with less hesitation, and inhaled more frequently. Also, pleasant emotional and physiological effects discriminated continuers from quitters. Nonsmokers appeared to possess more effective response strategies to refuse cigarettes. Implications of these data for prevention program design are discussed.

Contributions of the social context to the development of adolescent substance use: a multivariate latent growth modeling approach

This article demonstrates a latent growth curve methodology for analyzing longitudinal data of adolescent substance use. Hypotheses concerning the form of growth in alcohol, cigarette, and marijuana use, and covariates influencing the form of growth, were tested. Participants were male and female adolescents (n = 664) assessed at three time points. A common trajectory existed across the developmental period with significant increases in all three substances. Second-order multivariate extensions of the basic latent growth modeling framework suggested that associations among the individual differences parameters, representing growth or change in the various substance use behaviors, could be adequately modeled by a higher-order substance use construct. Inept parental monitoring, parent-child conflict, peer deviance, academic failure, gender, and age, were significant predictors of initial levels and the trajectory of substance use.

The critical role of nurturing environments for promoting human well-being.

The recent Institute of Medicine report on prevention (National Research Council & Institute of Medicine, 2009) noted the substantial interrelationship among mental, emotional, and behavioral disorders and pointed out that, to a great extent, these problems stem from a set of common conditions. However, despite the evidence, current research and practice continue to deal with the prevention of mental, emotional, and behavioral disorders as if they are unrelated and each stems from different conditions. This article proposes a framework that could accelerate progress in preventing these problems. Environments that foster successful development and prevent the development of psychological and behavioral problems are usefully characterized as nurturing environments. First, these environments minimize biologically and psychologically toxic events. Second, they teach, promote, and richly reinforce prosocial behavior, including self-regulatory behaviors and all of the skills needed to become productive adult members of society. Third, they monitor and limit opportunities for problem behavior. Fourth, they foster psychological flexibility-the ability to be mindful of ones thoughts and feelings and to act in the service of ones values even when ones thoughts and feelings discourage taking valued action. We review evidence to support this synthesis and describe the kind of public health movement that could increase the prevalence of nurturing environments and thereby contribute to the prevention of most mental, emotional, and behavioral disorders. This article is one of three in a special section (see also Muñoz Beardslee, & Leykin, 2012; Yoshikawa, Aber, & Beardslee, 2012) representing an elaboration on a theme for prevention science developed by the 2009 report of the National Research Council and Institute of Medicine.

A randomised controlled trial of a community intervention to prevent adolescent tobacco use

OBJECTIVE Experimental evaluation of comprehensive community wide programme to prevent adolescent tobacco use. DESIGN Eight pairs of small Oregon communities (population 1700 to 13 500) were randomly assigned to receive a school based prevention programme or the school based programme plus a community programme. Effects were assessed through five annual surveys (time 1–5) of seventh and ninth grade (ages 12–15 years) students. INTERVENTION The community programme included: (a) media advocacy, (b) youth anti-tobacco activities, (c) family communications about tobacco use, and (d) reduction of youth access to tobacco. MAIN OUTCOME MEASURE The prevalence of self reported smoking and smokeless tobacco use in the week before assessment. RESULTS The community programme had significant effects on the prevalence of weekly cigarette use at times 2 and 5 and the effect approached significance at time 4. An effect on the slope of prevalence across time points was evident only when time 2 data points were eliminated from the analysis. The intervention affected the prevalence of smokeless tobacco among grade 9 boys at time 2. There were also significant effects on the slope of alcohol use among ninth graders and the quadratic slope of marijuana for all students. CONCLUSION The results suggest that comprehensive community wide interventions can improve on the preventive effect of school based tobacco prevention programmes and that effective tobacco prevention may prevent other substance use.

Longitudinal changes in adolescent cigarette smoking behavior: Onset and cessation

Employing a 1-year longitudinal design, this study examined factors related to change in adolescent smoking. Predictors of smoking onset differed from predictors of continued smoking, underscoring the importance of studying factors related to adolescent smoking onset separately from mechanisms associated with changes in smoking among current smokers. Peer smoking predicted continuation of smoking after smoking initiation. Smokers received over 26 times more offers to smoke than did nonsmokers, suggesting that smokers attempting to quit need effective refusal skills to be successful. Habitual smoking was found to develop slowly, providing a substantial time window for refusal skill training and other prevention efforts. Predictors of smoking onset differed by developmental level. Peer smoking and marijuana use were stronger predictors of smoking onset for high-school students, and number of cigarette offers predicted better among middle-school students. Parent variables were not significant predictors of later smoking. Intention to smoke was unrelated to onset and was redundant with pretest smoking behavior in predicting cessation.

The integration of research and practice in the prevention of youth problem behaviors.

The prevention of youth problem behaviors is increasingly guided by science. Sound epidemiological research is coming to guide preventive efforts. Valid methods of monitoring the incidence and prevalence of youth problems increasingly shape preventive practice. The identification of empirically supported prevention interventions is becoming more sophisticated, and numerous scientific organizations have begun to engage in dissemination activities. These trends will be accelerated by increased media advocacy for the use of scientific methods and findings, the development of a registry of preventive trials, achievement of consensus about the standards for identifying disseminable interventions, and increased research on the factors that influence the effective implementation of science-based practices.