Addressing Common Risk and Protective Factors Can Prevent a Wide Range of Adolescent Risk Behaviors

Abstract

See Related Article p. 111 Adolescence and early adulthood are peak periods for engagement in a variety of risk behaviors, including delinquency, substance use, and sexual risk behavior. In recent US data, approximately 38% of sexually active high school students reported not using a condom at last intercourse, 36% of high school students reported being in a physical fight in the past year, 23% of 12th graders reported past-month heavy drinking, and 45% of 12th graders reported lifetime illicit drug use, including marijuana [1Johnston L.D. O'Malley P.M. Bachman J.G. et al.Monitoring the Future national results on adolescent drug use: Overview of key findings, 2008 (NIH Publication No. 09-7401). National Institute on Drug Abuse, Bethesda, Maryland2009Google Scholar, 2Centers for Disease Control and Prevention. 2007 National Youth Risk Behavior Survey Overview [Online]. Available at: http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbs07_us_overview.pdf. Accessed April 20, 2009.Google Scholar]. Readers of the Journal are likely well aware of the many negative consequences that can accompany these risk behaviors, including trouble with the law, school failure and dropout, substance abuse and dependence, unintended pregnancy, and human immunodeficiency virus (HIV) or sexually transmitted infection (STI) acquisition. The prevalence of adolescent and young adult risk behavior and the seriousness of the potential consequences speak loudly to the need for effective prevention programs that can be implemented universally to reduce the prevalence of these risk behaviors among adolescents and young adults. School-based programs are particularly useful, as they allow preventionists to reach nearly all children, they can be implemented before the onset of risk behavior, and they leverage a primary socializing environment in the lives of children [3Griffin K.W. Botvin G.J. Nichols T.R. Effects of a school-based drug abuse prevention program for adolescents on HIV risk behavior in young adulthood.Prev Sci. 2006; 7: 103-112Crossref PubMed Scopus (71) Google Scholar, 4Hawkins J.D. Catalano R.F. Broadening the vision of education: Schools as health promoting environments.J Sch Health. 1990; 60: 178-181Crossref PubMed Scopus (46) Google Scholar]. The history of prevention programs includes those focused on a single problem behavior and a limited range of targeted predictors. Although this single problem focus has resulted in a number of effective programs, it seems inefficient and perhaps financially prohibitive for schools to have to implement separate programs to address various prevalent risk behaviors. Indeed, school officials have become increasingly protective of school time for academic activities in an era in which they must meet academic performance benchmarks. Some researchers have called for a broader approach that would target multiple problems and multiple precursors, as well as increase positive outcomes for youth [5Catalano RF, Hawkins JD. Response from authors to comments on “Positive Youth Development in the United States: Research findings on evaluations of positive youth development programs.” Prevention and Treatment. Vol. 5, Article 20, June 24, 2002.Google Scholar, 6Hawkins J.D. Kosterman R. Catalano R.F. et al.Promoting positive adult functioning through social development intervention in childhood: Long-term effects from the Seattle Social Development Project.Arch Peds Adolesc Med. 2005; 159: 25-31Crossref PubMed Scopus (225) Google Scholar, 7Hawkins J.D. Catalano R.F. Kosterman R. et al.Preventing adolescent health-risk behaviors by strengthening protection during childhood.Arch Peds Adolesc Med. 1999; 153: 226-234PubMed Google Scholar]. As noted by Ellickson and colleagues [[8]Ellickson P.L. McCaffrey D.F. Klien D.J. Long-term effects of drug prevention on risky sexual behavior among young adults.J Adolesc Health. 2009; 45: 111-117Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar] in this issue of the Journal, adolescent and young adult risk behaviors often co-occur, in part because substance use may be causally related to sexual risk behavior and criminality [9Felson R.B. Teasdale B. Burchfield K.B. The influence of being under the influence: Alcohol effects on adolescent violence.J Res Crime Delinq. 2008; 45: 119-141Crossref Scopus (59) Google Scholar, 10Cooper M.L. Alcohol use and risky sexual behavior among college students and youth: Evaluating the evidence.J Stud Alcohol. 2002; 14: 101-117Google Scholar] and in part because all three types of behavior share a number of common risk and protective factors that may dispose youth toward risky or antisocial behavior [[11]Howell A.J. Enns R.A. A high risk recognition program for adolescents in conflict with the law.Can Psychol. 1995; 36: 149-161Crossref Google Scholar]. It should be possible, then, to design programs that would address multiple adolescent risk behaviors simultaneously. The results of the current study by Ellickson and colleagues [[8]Ellickson P.L. McCaffrey D.F. Klien D.J. Long-term effects of drug prevention on risky sexual behavior among young adults.J Adolesc Health. 2009; 45: 111-117Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar] suggest that targeting risk and protective factors in a substance use prevention program can have benefits, or “crossover effects,” for a broad range of adolescent risk behaviors that share these risk and protective factors. Furthermore, to the degree that substance use is causally related to sexual risk behavior and delinquency, the current findings suggest that reducing substance use may lead directly to reductions in these other two types of risk behavior. Specifically, the authors found that participation in either of two versions of Project ALERT was associated directly with reductions in two of the three sexual risk behaviors examined, and these reductions were partially mediated by reductions in problems associated with substance use, especially alcohol abuse. A particular strength of the study is that the authors tested differences in effectiveness between the ALERT program, delivered in middle school, and the longer ALERT Plus program, which included an additional 10 sessions in high school. The ALERT Plus program was not more effective in preventing sexual risk behavior than the shorter version—important cost-saving information for those wanting to implement the program. These results are in line with a growing body of research on crossover effects in school-based substance use prevention programs. For example, participation in the Seattle Social Development Project, now called the Raising Healthy Children intervention, delivered in elementary school was associated with reductions in violence, substance use, school dropout, and a range of sexual risk behaviors through age 21 years [6Hawkins J.D. Kosterman R. Catalano R.F. et al.Promoting positive adult functioning through social development intervention in childhood: Long-term effects from the Seattle Social Development Project.Arch Peds Adolesc Med. 2005; 159: 25-31Crossref PubMed Scopus (225) Google Scholar, 12Lonczak H.S. Abbott R.D. Hawkins J.D. et al.Effects of the seattle social development project on sexual behavior, pregnancy, birth, and sexually transmitted disease outcomes by age 21 years.Arch Pediatr Adolesc Med. 2002; 156: 438-447Crossref PubMed Scopus (178) Google Scholar, 13Hawkins J.D. Kosterman R. Catalano R.F. et al.Effects of social development intervention in childhood fifteen years later.Arch Pediatr Adolesc Med. 2008; 162: 1133-1141Crossref PubMed Scopus (146) Google Scholar]. Participation in the Life Skills Training program, administered in 7th, 8th, and 9th grades, was associated with a lower probability of violence, delinquency, risky driving, and HIV risk behavior 10 years after the intervention [3Griffin K.W. Botvin G.J. Nichols T.R. Effects of a school-based drug abuse prevention program for adolescents on HIV risk behavior in young adulthood.Prev Sci. 2006; 7: 103-112Crossref PubMed Scopus (71) Google Scholar, 14Botvin G.J. Griffin K.W. Nichols T.D. Preventing youth violence and delinquency through a universal school-based prevention approach.Prev Sci. 2006; 7: 403-408Crossref PubMed Scopus (207) Google Scholar, 15Griffin K.W. Botvin G.J. Nichols T.R. Long-term follow-up effects of a school-based drug abuse prevention program on adolescent risky driving.Prev Sci. 2004; 5: 207-212Crossref PubMed Scopus (55) Google Scholar]. In addition to programs focused on substance use prevention, programs designed to promote positive youth development in general also have shown reductions in a wide range of adolescent risk behaviors, including substance use and sexual risk behavior (e.g., Aban Aya, the HighScope Curriculum, Reach for Health, Gatehouse) [16Flay B.R. Graumlich S. Segawa E. et al.Effects of 2 prevention programs on high-risk behaviors among African American youth.Arch Pediatr Med. 2004; 158: 377-384Crossref PubMed Scopus (255) Google Scholar, 17Schweinhart L.J. Montie J. Xiang Z. et al.Lifetime effects: The High/Scope Perry Preschool study through age 40. High/Scope Press, Ypsilanti, Michigan2005Google Scholar, 18O'Donnell L. Stueve A. Doval A.S. et al.The effectiveness of the Reach for Health Community Youth Service Learning Program to reduce early and unprotected sex among urban middle school students.Am J Public Health. 1998; 89: 176-181Crossref Scopus (78) Google Scholar, 19Patton G.C. Bond L. Carlin J.B. et al.Promoting social inclusion in schools: A group-randomized trial of effects on student health risk behavior and well-being.Am J Public Health. 2006; 96: 1582-1587Crossref PubMed Scopus (204) Google Scholar]. These demonstrated positive effects have endured for years past the end of the interventions, often into adulthood. Taken together, these studies show that school-based substance use prevention programs can reduce a wide range of adolescent and young adult problem behaviors that carry significant risk for negative outcomes. Promising results like those from Project ALERT and other programs call for increased implementation of effective, school-based prevention programs aimed at influencing multiple risk and protective factors common to several prevalent problems during adolescence. Furthermore, these studies call for broader measurement of outcomes from these programs to ensure that the presence or absence of crossover effects is captured. Too frequently, because of single-problem–focused funding mechanisms, broader measurement of outcomes is not undertaken. The current study and others noted above help to define the foundation for future research on the potential crossover effects of prevention programs that target risk and protective factors common to multiple problems. Leveraging crossover effects may enhance the cost-effectiveness of prevention. Additional studies designed specifically to capture and understand crossover effects are needed. Future research should seek to ascertain the mechanisms of these preventive interventions, to highlight common mechanisms across studies, and to identify which mechanisms are most likely to show crossover effects. I thank Richard F. Catalano for his comments on an earlier draft of this editorial. Long-Term Effects of Drug Prevention on Risky Sexual Behavior Among Young AdultsJournal of Adolescent HealthVol. 45Issue 2PreviewThis study assesses the impact of a school-based drug prevention program, called Project ALERT, on risky sexual behavior among 1901 nonmarried, sexually active young adults who participated in one of two program variations as adolescents. It also tests for differences in program effect depending on program duration (middle school only vs. a combined middle school and high school program) and participants’ gender. Full-Text PDF