Adolescent Substance Abuse Prevention Research Articles

The Effect of Hurricane Katrina on Adolescent Feelings of Social Isolation

ObjectivesThis study investigates the effect of Hurricane Katrina on adolescent feelings of social isolation. Much anecdotal evidence suggests that individuals who continued to reside in New Orleans after Hurricane Katrina struck felt isolated from the rest of the country. Based on Durkheim's concept of anomie, we suggest that adolescents in New Orleans (and the Gulf region) may experience social isolation as a result of the hurricane.MethodsWe test this hypothesis with data from the Adolescent Substance Abuse Prevention Study, a multisite longitudinal study of adolescents in six cities around the United States.ResultsWe find that students in New Orleans are no different from students in the other five cities in their level of social isolation prior to the hurricane. In contrast, our posthurricane survey reveals significant differences between New Orleans (and Gulf region) students and students in the other five (comparison) cities in social isolation.ConclusionsOur findings lend contemporary support to the concept of anomie and suggest the importance of mental health interventions for adolescents immediately following a natural disaster.

Escalation of i.v. cocaine intake in peri-adolescent vs. adult rats selectively bred for high (HiS) vs. low (LoS) saccharin intake

Adolescence marks a period of increased vulnerability to the development of substance use disorders. High sweet preference is a genetically mediated behavioral trait that also predicts vulnerability to substances of abuse. Previous research has shown that while adolescent rats selectively bred for high (HiS) saccharin intake acquire cocaine self-administration at the same rate as adult HiS rats, adolescent rats bred for low saccharin intake (LoS) acquire cocaine self-administration faster than adult LoS rats. This study was conducted to investigate the interaction of the addiction vulnerability factors of peri-adolescence and saccharin preference on cocaine intake using an animal model of escalation of cocaine consumption over 6-h/day sessions. Peri-adolescent and adult HiS and LoS female rats self-administered i.v. cocaine (0.4mg/kg/inf) during short-access (2-h/day) sessions for 2days. Next, a long-access (6-h/day) period (LgA) commenced and lasted 16days. Following LgA, session length was returned to 2-h/day for a second short access phase. LoS peri-adolescent rats escalated cocaine intake over the LgA period and consumed more drug than LoS adult rats; however, peri-adolescent and adult HiS rats consumed similar amounts of cocaine during this period. Additionally, adult HiS rats self-administered more cocaine than adult LoS rats during the LgA period, while there was no phenotypic difference between the rat lines during peri-adolescence for the LgA period. During the first short-access phase, peri-adolescent rats self-administered more cocaine than adult rats. These results emphasize the importance of adolescent drug abuse prevention by illustrating that phenotypic protection from addiction may not be expressed until adulthood.

RURAL ADOLESCENT SUBSTANCE ABUSE: PREVENTION IMPLICATIONS FROM THE EVIDENCE

Purpose: To identify appropriate adolescent substance abuse prevention programming for rural populations through the application of three concepts: effectiveness (best clinical evidence), efficiency (benefit to rural populations), and equality (access). Methods: A review of the literature guided by these concepts was conducted to identify criteria essential to the tailored development of rural adolescent substance abuse prevention programming. An advanced search of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP) was then conducted using criteria tailored to rural populations. Findings: Results from the literature search support the inclusion of two components directed at improving quality of outcomes through a customized approach to rural adolescent substance abuse prevention programming: inclusion of parents in prevention education efforts and use of the Internet as an appropriate method of program delivery. These components were satisfied by one program listed on SAMHSA’s NREPP: Parenting Wisely . Conclusions: While Parenting Wisely is an ideal program for rural adolescent substance abuse prevention strategy, it may not be suitable for all communities. Parallel to recommendations from the SAMHSA and Institute of Medicine, other evidence-based prevention programs need to be expanded to include a web-based delivery option. Strategies for moving forward would include the use of advanced-practice nurses at the forefront of discussion for rural professionals, researchers, educators, and policymakers. Key Words: Access to Care, Technology, Substance Abuse Prevention, Rural

Effective Prevention of Adolescent Substance Abuse – Educational versus Deterrent Approaches

Substance abuse, especially among adolescents, has long been an important issue in society. In light of the adverse impact of substance abuse, scholars, educators, and policy-makers have proposed different approaches to prevent and reduce such abuse. This paper investigates the effectiveness of the two prominent approaches—educational and deterrent—in preventing and reducing adolescent substance abuse. The educational approach (e.g., school-based prevention programming) tends to be more comprehensive and better grounded in theories than the deterrent approach (e.g., drug testing). The educational approach not only targets multiple psychosocial factors contributing to substance abuse, but it is also supported by empirical studies showing that school-based prevention programming is effective in preventing substance abuse and has long-lasting positive influences on adolescent development. Practical implications of implementing school-based prevention programming are also discussed. L'abus d'alcool ou d'autres drogues, surtout chez les adolescents, constitue depuis longtemps une préoccupation importante de la société. À la lumière de l'impact défavorable de cet abus, les chercheurs, enseignants et décideurs ont proposé différentes approches pour le prévenir et le limiter. Cet article porte sur l'efficacité de deux approches importantes, l'une pédagogique, l'autre dissuasive, visant la prévention et la réduction de l'abus d'alcool ou d'autres drogues chez les adolescents. L'approche pédagogique (par ex. les programmes de prévention en milieu scolaire) est, de façon générale, plus globale et mieux fondée sur les théories que l'approche dissuasive (par ex. dépistage des drogues). Non seulement l'approche pédagogique cible-t-elle les divers facteurs psychosociaux qui contribuent à cet abus, elle est de plus appuyée par des études empiriques indiquant que les programmes de prévention en milieu scolaire sont des outils efficaces dans la prévention de l'abus d'alcool ou d'autres drogues et qu'ils ont un impact positif à long terme sur le développement des adolescents. Nous discutons des répercussions pratiques de la mise en œuvre des programmes de prévention en milieu scolaire.

Effective Prevention of Adolescent Substance Abuse – Educational versus Deterrent Approaches

Substance abuse, especially among adolescents, has long been an important issue in society. In light of the adverse impact of substance abuse, scholars, educators, and policy-makers have proposed different approaches to prevent and reduce such abuse. This paper investigates the effectiveness of the two prominent approaches—educational and deterrent—in preventing and reducing adolescent substance abuse. The educational approach (e.g., school-based prevention programming) tends to be more comprehensive and better grounded in theories than the deterrent approach (e.g., drug testing). The educational approach not only targets multiple psychosocial factors contributing to substance abuse, but it is also supported by empirical studies showing that school-based prevention programming is effective in preventing substance abuse and has long-lasting positive influences on adolescent development. Practical implications of implementing school-based prevention programming are also discussed. L'abus d'alcool ou d'autres drogues, surtout chez les adolescents, constitue depuis longtemps une preoccupation importante de la societe. A la lumiere de l'impact defavorable de cet abus, les chercheurs, enseignants et decideurs ont propose differentes approches pour le prevenir et le limiter. Cet article porte sur l'efficacite de deux approches importantes, l'une pedagogique, l'autre dissuasive, visant la prevention et la reduction de l'abus d'alcool ou d'autres drogues chez les adolescents. L'approche pedagogique (par ex. les programmes de prevention en milieu scolaire) est, de facon generale, plus globale et mieux fondee sur les theories que l'approche dissuasive (par ex. depistage des drogues). Non seulement l'approche pedagogique cible-t-elle les divers facteurs psychosociaux qui contribuent a cet abus, elle est de plus appuyee par des etudes empiriques indiquant que les programmes de prevention en milieu scolaire sont des outils efficaces dans la prevention de l'abus d'alcool ou d'autres drogues et qu'ils ont un impact positif a long terme sur le developpement des adolescents. Nous discutons des repercussions pratiques de la mise en œuvre des programmes de prevention en milieu scolaire.

Preventing growth in amphetamine use: long‐term effects of the Midwestern Prevention Project (MPP) from early adolescence to early adulthood

The aim of the current study was to examine the long-term effect of an early adolescent substance abuse prevention program on trajectories and initiation of amphetamine use into early adulthood. Eight middle schools were assigned randomly to a program or control condition. The randomized controlled trial followed participants through 15 waves of data, from ages 11-28 years. This longitudinal study design includes four separate periods of development from early adolescence to early adulthood. The intervention took place in middle schools. A total of 1002 adolescents from one large mid-western US city were the participants in the study. The intervention was a multi-component community-based program delivered in early adolescence with a primary emphasis on tobacco, alcohol and marijuana use. At each wave of data collection participants completed a self-report survey that included questions about life-time amphetamine use. Compared to a control group, participants in the Midwestern Prevention Project (MPP) intervention condition had reduced growth (slope) in amphetamine use in emerging adulthood, a lower amphetamine use intercept at the commencement of the early adulthood and delayed amphetamine use initiation. The pattern of results suggests that the program worked first to prevent amphetamine use, and then to maintain the preventive effect into adulthood. Study findings suggest that early adolescent substance use prevention programs that focus initially on the 'gateway' drugs have utility for long-term prevention of amphetamine use.

Family Together: Developing a Family Educational Program against Drug Abuse in Taipei County

Adolescent drug abuse has become a serious problem in Taiwan. Therefore, the main purpose of this research was to develop a program for the high-risk adolescents and their parents to prevent adolescent substance abuse in Taipei County, Taiwan. The program named ”Family Together” focused on emotional management, communication, and adolescent substance abuse prevention. The features of the research include Family-based program, Evaluation, Alliance, Science-based, and Training (FEAST). Fifty high-risk students and thirty-four parents from three junior high schools in Taipei County participated in the program. The program includes six steps which are draw-up, coordination, training, implementation, evaluation, and dissemination. The Family Together program had been found to be effective. The program could improve the attitudes toward and knowledge of communication and the knowledge and skills regarding prevention of adolescent substance abuse among the parents. In addition, the program could improve the knowledge of and attitudes toward emotional management and communication, knowledge of substance abuse, and willingness to use refusal skills among the adolescents. The future efforts might focus on strengthening seed-teacher training program and involving general community adolescents and their parents to participate the program. Furthermore, suggestions for government to promote family-based program are also provided.

A demographic–economic model for adolescent substance abuse and crime prevention

A demographic–economic model is used to estimate the impact of evidenced-based, substance-abuse social intervention that addresses delinquent crime. If ramped-up with more extensive financing, prevention would have many beneficial effects on drug and behavioral problems of delinquent youth. Historical data show drug use accelerates in the 14–15 year age group and peaks in the 18–20 year age group and then begins to decline until age 30. Over a 1-year interval, African Americans aged 12–17 have been found to use illicit drugs at a rate of 14% and Whites at 17%; however, African American youth drug offenses are 51% higher than comparable White youth offenses. Significant economic costs are generated by the disproportionate criminal justice outcomes experienced by African American adolescents, and cost savings are calculated. Two scenarios are developed to illustrate the effect of expanded programming for at-risk youths. A decline in residential placement in the juvenile justice system is projected along wit...

The Adolescent Substance Abuse Prevention Study: A randomized field trial of a universal substance abuse prevention program

Objectives The purpose of the study was to determine whether a universal school-based substance abuse prevention program, Take Charge of Your Life ( TCYL), prevents or reduces the use of tobacco, alcohol, or marijuana. Methods Eighty-three school clusters (representing school districts) from six metropolitan areas were randomized to treatment (41) or control (42) conditions. Using active consenting procedures, 19,529 seventh graders were enrolled in the 5-year study. Self-administered surveys were completed by the students annually. Trained Drug Abuse Resistance Education (D.A.R.E.) police officers presented TCYL in seventh and ninth grades in treatment schools. Analyses were conducted with data from 17,320 students who completed a baseline survey. Intervention outcomes were measured using self-reported past-month and past-year use of tobacco, alcohol, and marijuana when students were in the 11th grade. Results Main effect analyses show a negative program effect for use of alcohol and cigarettes and no effect for marijuana use. Subgroup analyses indicated that the negative effect occurred among nonusers at baseline, and mostly among white students of both genders. A positive program effect was found for students who used marijuana at baseline. Two complementary papers explore the relationship of the targeted program mediators to the use of alcohol, tobacco, and marijuana and specifically for students who were substance-free or who used substances at baseline. Conclusions The negative impact of the program on baseline nonusers of alcohol and tobacco indicate that TCYL should not be delivered as a universal prevention intervention. The finding of a beneficial effect for baseline marijuana users further supports this conclusion. The programmatic and methodological challenges faced by the Adolescent Substance Abuse Prevention Study (ASAPS) and lessons learned offer insights for prevention researchers who will be designing similar randomized field trials in the future.

Is the Receptivity of Substance Abuse Prevention Programming Affected by Students' Perceptions of the Instructor?

Drawing on the elaboration likelihood model of persuasive communication, the authors examine the impact of the perceptions of the instructor or source on students' receptivity to a new substance abuse prevention curriculum. Using survey data from a cohort of students participating in the Adolescent Substance Abuse Prevention Study, the authors use structural equation modeling to determine the effects of the perceptions students have of their program instructor on measures of the targeted program mediators and the use of cigarettes, alcohol, and marijuana. They test these instructor effects after each component of a two-part curriculum is administered (during the seventh and ninth grades). They find that the perceptions of the instructor significantly affect refusal, communication and decision-making skills, normative beliefs, perceived consequences of use, and substance use. The authors discuss the implications of these findings for school-based prevention programming and indications for further research.

Reports of Substance Abuse Prevention Programming Available in Schools

Evaluations of school-based substance abuse prevention programs with schools or school districts randomly assigned to either the treatment or control condition have demonstrated effective strategies over the past 30 years. Although control schools were never considered "pure" (i.e., no other interventions were being offered), school-based programming in the 1980s did not include evidence-based interventions. Since the late 1990s, funding agencies have required schools either to select programming from approved lists of prevention strategies or to demonstrate the efficacy of the strategies that would be used. This has increased the number of schools delivering evidence-based programs to their students. As a result, "treatment as usual" is more challenging to researchers. This paper describes exposure to prevention programming as reported by 204 school administrators from 83 districts and their 19,200 students who are participating in the Adolescent Substance Abuse Prevention Study, a national randomized evaluation trial of the program, Take Charge of Your Life. In order to determine the extent of student exposure to prevention programming in both the control and treatment schools, data were collected in each of the 5 years of the study from two sources: principals and prevention coordinators and from students. The data provided by the principals and prevention coordinators indicate that the vast majority of schools assigned to the control condition offered students drug prevention programming. This finding has implications for the evaluation of Take Charge of Your Life but also for other evaluation studies. The students were asked questions regarding participation in drug education posed on annual surveys. When their responses were compared to the reports from their school principals and prevention coordinators, it was found that the students underreported exposure to drug education. A follow-up qualitative study of a sample of students suggests the need for rewording of the questions for students in future studies. The implications of our findings for evaluation studies are discussed.

Implementation fidelity: the experience of the Adolescent Substance Abuse Prevention Study

While researchers have developed more effective programs and strategies to prevent the initiation of substance use and increasingly communities are delivering these interventions, determining the degree to which they are delivered as they were designed remains a significant research challenge. In the past several years, more attention has been given to implementation issues during the various stages of program development and diffusion. This paper presents the findings from a substudy of an evaluation of a newly designed middle and high school substance abuse prevention program, Take Charge of Your Life delivered by local Drug Abuse Resistance Education officer instructors. A key aspect of the study was to determine the extent to which implementation fidelity, using the measures of content coverage and appropriate instructional strategy, was associated with improvement in the program mediators of realistic normative beliefs, understanding the harmful effects of substance use and the acquisition of decision-making and resistance skills. Although it was found that higher fidelity was associated with better scores on some of the mediators, this was not a consistent finding. The mixed results are discussed within the context of the lesson activities themselves.

New Initiatives in Improving Youth and Family Outcomes by Importing Evidence-Based Practices

ABSTRACT This article describes three community-based research projects that are designed to enhance the effectiveness of real-world adolescent substance abuse treatment and prevention, and presents preliminary study results from each. The first project is examining statewide public sector practitioner interest in and implementation of contingency management in treating adolescent substance abuse. The second project is integrating the Community Reinforcement Approach for adults into Multisystemic Therapy (MST) programs for use with substance-abusing caregivers. The third project is integrating Reinforcement-Based Therapy for adults with MST for child abuse and neglect in the treatment of families with co-occurring child maltreatment and caregiver substance abuse. Each project highlights the complexity of using the evidence base in the treatment of substance abuse, and the potential to improve outcomes for challenging clinical populations in real world practice settings.

Estimating the Differential Costs of Criminal Activity for Juvenile Drug Court Participants: Challenges and Recommendations

Juvenile drug court (JDC) programs have expanded rapidly over the past 20 years and are an increasingly popular option for rehabilitating juvenile offenders with substance use problems. Given the high cost of crime to society, an important economic question is whether and to what extent JDC programs reduce criminal activity among juvenile offenders. To address this question, the present study added an economic cost analysis to an ongoing randomized trial of JDC conducted in Charleston, South Carolina. Four treatment conditions were included in the parent study: Family Court with usual community-based treatment (FC, the comparison group), Drug Court with usual community-based treatment (DC), DC with Multisystemic Therapy (DC/MST), and DC/MST enhanced with Contingency Management (DC/MST/CM). The economic study estimated the cost of criminal activity for nine specific crimes at baseline (pretreatment) and 4 and 12 months thereafter. A number of methodological challenges were encountered, suggesting that it may be more difficult to economically quantify frequency and type of criminal activity for adolescents than for adults. The present paper addresses methodological approaches and challenges, and proposes guidelines for future economic evaluations of adolescent substance abuse and crime prevention programs.

The Juvenile and Adolescent Substance Abuse Prevention Program: An evaluation.

Today, statistics indicate a sudden increase in drug and alcohol abuse prevention programs in the school systems of the United States. This increase in drug prevention programs has been triggered by the increase in drug and alcohol use by adolescents between the ages of 12-17 years of age. According to the Youth Risk Behaviors Survey (YRBS), from the years 1991 to 1999, lifetime marijuana and cocaine use increased each year by a mode of [+ or -] 2.5% among American students in the 9th to 12th grades. Between the years 1999 to 2005, the lifetime use of both drugs decreased, but the decrease of current cocaine use (use within the 30 days prior to the survey) did not begin until 2001. Illegal steroid use increased among this same age group during the years of 1991 to 2003, and a decrease was seen from 2003 to 2005. As the new millennium begins to take shape, the use of illegal drugs has decreased and the question is, is it due to the increase of youth drug and alcohol prevention programs? Several studies have tested the effectiveness of these programs and the Juvenile and Adolescent Substance Abuse Prevention (JASAP) program of Atlanta, Georgia is one of these effective programs. Belgrave, Reed, Plybon, and Corneille (2004) used the Specific Event Drug and Alcohol Refusal Efficacy Scale (SEDARE) to measure the effectiveness of a drug abuse prevention program for urban African American girls. The SEDARE was used to show the probability of drug use among these girls in certain situations. The situations in which the girls viewed themselves as being able to refuse drugs and alcohol varied; but of the 92 girls that participated, the girls in the intervention group had a higher drug and alcohol refusal rate as measured by the SEDARE than the girls in the control group. According to the study, 67% of the intervention group stated that they could refuse drugs and alcohol as opposed to the 33% of the comparison group who stated that they could refuse drugs and alcohol in the same situation. Most of the situations that were measured by the SEDARE were associated with peer relationships. With Project KICK (Kids In Cooperation with Kids) Rollins, Rubin, and Wright (1999) used the community partnership, drug education, parent involvement, and peer counseling to evaluate the effectiveness of this program versus the programs that are only taught in the schools. Elementary school students from a mid sized southeastern city in Florida were the actual participants, and seventh graders served as the peer mentors to two classrooms of third graders. The Curriculum used for project KICK is composed of nine units that the students will master upon completion. The Questionnaire used by Rollins et al(1999) measured attitudes related to substance abuse, teenage pregnancy prevention, school attitudes, aggressive behavior, and stress reduction. The purpose of this program was to not only provide substance abuse prevention and education, but also to create a support base within the community where the pressure to try alcohol and drugs is lessened. In 1993, Ellickson, Bell, and McGuigan did a longitudinal study over six years that achieved reduced drug use during the years of junior high school. The curriculum used consisted of eleven lessons and was tested in 30 schools in eight highly diversified communities on the west coast. The curriculum focused on providing the 7th and 8th grade students the skills needed to resist drug and alcohol use. Throughout the program, approximately 4000 7th grade students were assessed six times (once every year) after the program was completed until grade 12. The results of this particular program were that as soon as the program was completed, the effects on drug use ended. Ellickson et al. (1993) found that the cognitive risk factors continued until the 10th grade for most of the students, but over all found that it is doubtful that early prevention is effective without some form of continued prevention efforts during high school. …

Moving the Risk and Protective Factor Framework Toward Individualized Assessment in Adolescent Substance Abuse Prevention

ABSTRACT The field of substance abuse prevention has evolved towards a risk and protective factor paradigm in explaining the onset and escalation of adolescent substance use. This framework for understanding the problem has been developed and employed by researchers at the University of Washington, under Doctors Hawkins and Catalano, to assess communities for high-risk and low protection. Currently, there are no individual instruments to assess adolescents on these risk and protective factors. This article argues for the need of such an instrument, one that is time manageable and comprehensive. It is suggested that using a two-step method for assessment could meet these goals.

Research Note: An Empirical Study of Adolescent Student Attrition

Sample attrition, a major concern in any longitudinal study, is even more problematic when adolescents are the study population. The need to minimize the loss of participants in order to maintain the integrity of the cohort is vital in substance abuse prevention evaluations. The Adolescent Substance Abuse Prevention Study (ASAPS), a national school based prevention study being conducted in six sites across the country, followed students attending schools randomly assigned to either a treatment or control condition from the seventh through the eleventh grade. The percent of study dropouts after the ninth grade pretest warranted consideration of an attrition study to acquire data from those students who were no longer in a study school. A pilot study conducted with a sample of attrition cases in one site (51 of 495) was undertaken to assess the feasibility and costs of a full study. This paper describes the experiences gained from this pilot study in tracking study subjects. An exhaustive protocol was developed and contacts with parents were initiated through telephone calls and flyers sent by mail. Online public records and telephone directories were used to acquire additional contact information. Contact was established with 56.8% of the parents and resulted in completed surveys from 19.6% of the sample at a cost of $1,949.30 per survey.

The Principle of Cultural Grounding in School-Based Substance Abuse Prevention

Culture plays an important role in all health message design, and school-based substance abuse prevention is no exception. Because most adolescent substance abuse prevention programs in the United States are delivered in schools, this is particularly important given the diversity of the students. Unfortunately, there is little theory to guide these programs and fewer programs that successfully achieve cultural competence. Using communication accommodation theory as a framework, this article articulates the principle of cultural grounding using the Drug Resistance Strategies Project as an exemplar. The article then describes a line of research describing youth, ethnic, and gender cultures leading to the development and evaluation of the keepin’ it REAL curriculum. Results demonstrate the efficacy of a multicultural approach to prevention in controlling the onset of adolescent drug use.

Prevention of adolescent drug abuse: Targeting high-risk children with a multifaceted intervention model— The Early Risers “Skills for Success” Program

This article describes a comprehensive drug abuse preventive intervention called the Early Risers “Skills for Success” Program. Early Risers is an example of an indicated prevention strategy designed to alter the developmental trajectory leading to drug use and abuse in high-risk children as indexed by the presence of early-onset aggressive behavior. An “early-starter” developmental model to alcohol, tobacco, and other drugs provides the theoretical underpinnings for selection of the program's child and family intervention targets. Social development and social ecology theories provide the conceptual foundation for content of the major intervention components, CORE and FLEX, respectively. CORE is a coordinated set of standardized child-focused interventions that promote developmental competence by teaching skills pertinent to emotional regulation, prosocial peer affiliation, and school adjustment. This component is delivered within the context of child- and parent-focused education and skills training programs during summer and regular school year periods. The FLEX component is a family support, empowerment, and service-brokerage intervention that is individually tailored in response to the unique assets and needs of individual families. Access to services is organized by home-visiting family advocates who provide consultation, support, and brief interventions to assist families in solving daily hardship and stress-related problems. When more serious basic living and health problems are identified, family advocates broker specialized services with community agencies.

Family predictors of parent participation in an adolescent drug abuse prevention program

Low participation rates constitute a serious problem faced by family drug abuse prevention programs. In this study we analyse the factors related to participation in a Life Skills Training program implemented in three schools in Spain. Participants in the study were 485 pupils aged 12 - 14 years and their respective parents. The variables that predicted participation in the program were: number of children and educational level of parents, children's drug use, family conflict, parental rearing style, relationships between parents and children and family communication. The results from Spain are similar to those found in international studies, and indicate that the families most at risk of drug use are those least likely to participate in prevention programs. There is a need for strategies to increase participation in prevention programs of the families most at risk.