PRINCIPLES OF SUBSTANCE ABUSE PREVENTION
FOR EARLY CHILDHOOD:
A RESEARCH-BASED GUIDE
P
ublished in 2016, this report offered stakeholders information on
principles of prevention for use in the early years of a child’s life (prenatal
through age 8). For the latest information on prevention research, visit
N
IDA’s Prevention webpage.
P
ublication Date: March 2016
PRINCIPLES OF SUBSTANCE ABUSE PREVENTION
FOR EARLY CHILDHOOD:
A RESEARCH-BASED GUIDE
This publication is available for your use and may be reproduced in its entirety without
permission from NIDA. Citation of the source is appreciated, using the following language:
Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of
Health and Human Services.
The U.S. government does not endorse or favor any specific commercial product or company. Trade,
proprietary, or company names appearing in the publication are used only because they are considered
essential in the context of the studies described here.
March 2016
Table of Contents
Acknowledgements .......................................................................................................................................................................... 1
Introduction ........................................................................................................................................................................................ 3
Principles of Substance Abuse Prevention for Early Childhood ..................................................................................... 7
Principle 1 (Overarching Principle): Intervening early in childhood can alter the life course trajectory in
a positive direction ....................................................................................................................................................................... 7
Principle 2: Intervening early in childhood can both increase protective factors and reduce risk factors7
Principle 3: Intervening early in childhood can have positive long-term effects ................................................ 7
Principle 4: Intervening in early childhood can have effects on a wide array of behaviors ............................ 7
Principle 5: Early childhood interventions can positively affect children’s biological functioning ............. 8
Principle 6: Early childhood prevention interventions should target the proximal environments of the
child .................................................................................................................................................................................................... 8
Principle 7: Positively affecting a child’s behavior through early intervention can elicit positive
behaviors in adult caregivers and in other children, improving the overall social environment ................. 8
Chapter 1: Why is Early Childhood Important to Substance Abuse Prevention? ................................................... 11
What does the life course perspective show about risk for drug abuse and how to prevent it? ................. 12
What are the major influences on a child’s early development? .............................................................................. 14
Chapter 2: Risk and Protective Factors .................................................................................................................................. 21
What are some important early childhood risk factors for later drug use? ......................................................... 21
What if a child has multiple risk factors?........................................................................................................................... 26
What are some important protective factors that can offset risk factors? ........................................................... 28
Chapter 3: Intervening in Early Childhood ........................................................................................................................... 33
What contexts do early childhood interventions target? ............................................................................................ 37
Do early childhood interventions target all children or just those at highest risk? .......................................... 38
What are some characteristic features of early childhood interventions? ........................................................... 39
How does changing the behavior of parents and teachers help children? ........................................................... 42
Who benefits the most from early childhood interventions? .................................................................................... 42
Chapter 4: Research-Based Early Intervention Substance Abuse Prevention Programs ................................... 47
Prenatal/Infancy and Toddlerhood (Ages 0 to 3 Years).............................................................................................. 49
Universal Programs ............................................................................................................................................................... 49
Durham Connects. .............................................................................................................................................................. 49
Selective Programs ................................................................................................................................................................. 49
Early Steps, Family Check-Up (Early Steps FCU). .................................................................................................. 49
Family Spirit. ........................................................................................................................................................................ 50
Nurse Family Partnership. .............................................................................................................................................. 51
Preschool (Ages 3 to 6 Years) ................................................................................................................................................ 52
Selective Programs ................................................................................................................................................................. 52
Multidimensional Treatment Foster Care for Preschoolers (MTFC-P) ......................................................... 52
Transition to School (Ages 6 to 8 Years) ............................................................................................................................ 53
Universal Programs ............................................................................................................................................................... 53
Caring School Community Program ............................................................................................................................ 53
Classroom-Centered (CC) Intervention. .................................................................................................................... 54
Linking the Interests of Families and Teachers (LIFT). ...................................................................................... 55
Raising Healthy Children (RHC). .................................................................................................................................. 56
SAFEChildren. ...................................................................................................................................................................... 57
Seattle Social Development Project (SSDP). ............................................................................................................ 58
Selective Programs ................................................................................................................................................................. 59
Early Risers “Skills for Success” Risk Prevention Program. .............................................................................. 59
Kids in Transition to School (KITS). ............................................................................................................................ 60
Tiered Programs ................................................................................................
..................................................................... 60
Fast Track Prevention Trial for Conduct Problems. .............................................................................................
60
Incredible Years Parents, Teachers, and Children’s Training Series. ......................................................... 62
Positive Action (PA). ......................................................................................................................................................... 63
School and Homes in Partnership (SHIP). ................................................................................................................ 64
Chapter 5: Selected Resources ................................................................................................................................................... 69
Appendix 1: From Theory to Outcomes—Designing Evidence-Based Interventions .......................................... 79
Intervention Timing, Context, and Components .............................................................................................................
80
Program Evaluation and Assessment of Benefit-C
ost .................................................................................................. 81
Appendix 2: Selecting and Implementing an Intervention ............................................................................................. 85
Determining Community Risk and Protective Factors ................................................................................................. 85
Identifying the Target Population ........................................................................................................................................ 88
Adapting Programs .................................................................................................................................................................... 89
Collecting Data ............................................................................................................................................................................. 89
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 1
This publication was written by Elizabeth B. Robertson, Ph.D., University of Alabama
(formerly with the National Institute on Drug Abuse), Belinda E. Sims, Ph.D., National
Institute on Drug Abuse, and Eve E. Reider, Ph.D., National Center for Complementary and
Integrative Health. It was edited by Eric Wargo, Ph.D., National Institute on Drug Abuse.
NIDA wishes to thank the following individuals for their guidance and comments during
the development and review of this publication:
Karl G. Hill, Ph.D.
University of Washington
Nicholas S. Ialongo, Ph.D.
Johns Hopkins University
Leslie Leve, Ph.D.
University of Oregon
David L. Olds, Ph.D.
University of Colorado
Naomi Stotland, M.D.
University of California, San Francisco
NIDA also would like to thank the Community Anti-Drug Coalitions of America (CADCA) for
helping organize a focus group of community leaders in reviewing this publication and the
following individuals who participated in the focus group:
B.J. Boyd, Ph.D.
Cherokee National Behavioral Health
Velma Overman
Starfish Family Services
Tanya Roberts
Families in Action, Inc.
Heather Warner
Strategic Planning Initiative for Families and Youth
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 2
NIDA wishes to thank the following individuals for their contributions to the development
of this publication:
Nona Lu, M.D.
Vanderbilt University
Marisa Pinchas, M.P.H.
Children’s Hospital Los Angeles
Sarah D. Lynne Landsman, Ph.D.
University of Florida
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 3
Substance abuse and addiction are preventable disorders that interfere with normal
healthy functioning, contributing to physical and behavioral health problems, injuries, lost
income and productivity, and family dysfunction. While substance use generally begins
during the adolescent years, there are known biological, psychological, social, and
environmental factors that contribute to the risk that begin accumulating as early as the
prenatal period. This creates opportunities to intervene very early in an individual’s life
and thereby prevent substance use disorders—and, along with them, a range of other
related behavioral problems—long before they would normally manifest themselves.
The second edition of NIDA’s Preventing Drug
Abuse Among Children and Adolescents (2003)
noted that “early intervention can prevent
many adolescent risks.” This special
supplement to that volume reflects a growing
body of research that has continued to
accumulate showing that providing a stable
home environment, adequate nutrition,
physical and cognitive stimulation, warm
supportive parenting, and good classroom
management in the early years of a child’s life
(prenatal through age 8) can lead the child to
develop strong self-regulation (i.e., emotional
and behavioral control) and other qualities
that protect against a multitude of risks and
increase the likelihood of positive developmental outcomes. Positive effects of these
interventions include delayed initiation and decreased use of drugs when the child reaches
adolescence.
By adolescence, children’s attitudes, behaviors, family interactions, and relationships—
factors that may influence propensity to try or become addicted to drugs—are well
established and not as easily changed. For young children already exhibiting serious risk
factors for later drug use, delaying intervention until later childhood or adolescence may
make it more difficult to overcome accumulated risk factors and achieve positive outcomes.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 4
Our increased understanding of brain development and neuroplasticity across the first two
decades of life also supports implementing early intervention. The prenatal, child, and
adolescent brain is undergoing rapid and significant change, including the formation of new
synapses and, after about age 5, the progressive pruning of unused synaptic connections
and reinforcement of major circuits. Synaptic plasticity makes early childhood extremely
sensitive to experiences and environmental influences (including family interactions and
social contexts) that may act either as risk factors for later drug use and related problems
or that may be protective against those risks. Thus the earlier an intervention occurs, the
greater the potential to take advantage of biological, emotional, and behavioral sensitive
periods to alter the course of development in a positive, healthy direction.
Research supports the value of interventions
that reduce risk factors, promote protective
factors, and increase access to resources (e.g.,
school- and community-based family support
services) in th
e lives of young children and those
closest to them. Su
bstantial data from many
long-term studies now indicate that intervening
with children and families who are showing
early risk factors for substance abuse is
effective, and the benefits of such interventions
continue into adolescence and young adulthood
and even into adulthood.
Research has also found that a large number of
early risk factors for substance abuse are
simultaneously risk factors for other mental, emotional, and behavior problems. For
example, early-onset externalizing behavior problems, such as aggressive and disruptive
behaviors in the preschool years, have been found to relate to increased risk for outcomes
such as conduct disorders, substance use, delinquency, and risky sexual behaviors in
adolescence. Given that this is the case, it is not surprising that interventions designed to
prevent substance abuse have shown many positive benefits that extend to other
outcomes—including improved personal, social, and familial functioning; higher academic
and career achievement; and less involvement with the juvenile justice system and mental
health services.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 5
Early childhood prevention interventions can be
costly to implement, but the research balancing the
benefits of these programs against their costs
shows they are good—occasionally very good—
investments. Among interventions for which such
data are available, savings range from $2.88 for
every dollar invested (the Nurse-Family
Partnership, described in Research-Based Early
Intervention Substance Abuse Prevention
Programs) to as much as $25.92 (the Good
Behavior Game, used in the Classroom-Centered
Intervention) (Aos et al., 2004). Thus, a well-
conceived and well-implemented intervention for
very young children can not only dramatically
improve the quality of life for the children and families involved but also benefit the
community and society as a whole.
This guide, intended for parents, practitioners, and policymakers, begins with a list of 7
principles addressing the specific ways in which early interventions can have positive
effects on development; these principles reflect findings on the influence of intervening
early with vulnerable populations on the course of child development and on common
elements of successful early childhood programs. This is followed, in “Why is Early
Childhood Important to Substance Abuse Prevention?” and “Risk and Protective Factors,”
with an overview of child development from the prenatal period through age 8 (the span
covered by this resource) and the various factors that either place a child at risk for later
substance use or offer protection against that risk.
“Intervening in Early Childhood” describes
common elements of early childhood
interventions that target individual, family,
school, and community precursors of drug
use, abuse, and addiction. “Research-Bas
ed
Early Intervention Substance Abuse
Prevention Programs” includes information
on specific early childhood intervention
p
rograms for which the National Institute
on Drug Abuse (NIDA) has provided
research support, and a section on “Selected
Resources” provides links to many Federal
agencies, professional and academic
organizations, and non-governmental
agencies that engage in early-childhood-
prevention–related initiatives. Two appendices for policymakers, researchers, and
practitioners go into greater detail on how early childhood interventions are designed and
how to select the right intervention for a community’s specific needs.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 6
The “Selected References” include up-to-date sources that provide more in-depth coverage
of all of the concepts, principles, and programs discussed.
Early childhood risks can lead to immediate and long-term problems that increase a child’s
chances of substance abuse and other problems in adolescence and later in life. It is now
known that intervening early is a worthwhile strategy for setting children on a healthier
path that may avoid these difficulties. NIDA hopes that this guide is helpful to substance
abuse prevention efforts for children at home, in schools, and in communities nationwide.
Selected Reference
Aos S, Lieb R, Mayfield J, Miller M, Pennucci A. Benefits and costs of prevention and early
intervention programs for youth. Olympia, WA: Washington State Institute for Public
Policy; 2004. Document No. 04-07-3901.
http://www.wsipp.wa.gov/ReportFile/881/Wsipp_Benefits-and-Costs-of-Prevention-and-
Early-Intervention-Pro
grams-for-Youth_Summary-Report.pdf. Published September 17,
2004. Accessed February 3, 2015.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 7
Seven principles of prevention for early childhood (which is defined here as the prenatal
period and infancy through the transition to elementary school around age 8) have
emerged from research studies funded (in full or in part) by NIDA. The detailed rationale
for these principles appears in “Why is Early Childhood Important to Substance Abuse
Prevention?,” “Risk and Protective Factors,” and “Intervening in Early Childhood.”
Principle 1 (Overarching Principle): Intervening early in childhood can alter the life
course trajectory in a positive direction
(Kellam et al., 2008; Kitzman et al., 2010).
Substance abuse and other problem behaviors that manifest during adolescence have their
roots in the developmental changes that occur earlier—as far back as the prenatal period.
While prevention can be effective at any age, it can have particularly strong effects when
applied early in a person’s life, when development is most easily shaped and the child’s life
is most easily set on a positive course.
The following specific principles collectively provide support for Principle 1.
Principle 2: Intervening early in childhood can both increase protective factors and
reduce risk factors
(August et al., 2003; Catalano et al., 2003).
Risk factors are qualities of
children and their environments that place children at greater risk of later behavioral
problems such as substance abuse; protective factors are qualities that promote successful
coping and adaptation and thereby reduce those risks. All children have a mix of both.
Interventions aim to shift the balance toward protective factors.
Principle 3: Intervening early in childhood can have positive long-term effects
(Degarmo et al., 2009; Shaw et al., 2006).
Early childhood interventions focus on settings
and behaviors that may not appear relevant for adjustment later in childhood or in
adolescence, but they help
set the stage for positive self-regulation and other protective
factors that ultimately reduce the risk of drug use.
Principle 4: Intervening in early childhood can have effects on a wide array of
behaviors
(Beets et al., 2009; Hawkins et al., 2008; Snyder et al., 2010), even behaviors not
specifically targeted by the intervention (Hawkins et al., 1999; Kellam et al., 2014; Lonczak
et al., 2002). Because behaviors (both positive and negative) are linked to each other, risk
factors for substance use may simultaneously put a child at risk for other problems such as
mental illness or difficulties at school. This is why intervening to prevent one undesirable
outcome may have a broad effect, improving the child’s life trajectory in multiple ways.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 8
Principle 5: Early childhood interventions can positively affect children’s biological
functioning
(Bruce et al., 2009; Fisher et al., 2007).
The benefits of intervention are not
limited to behavioral or psychological outcomes—research has shown they can also affect
physical health. For example, one intervention for young children in the foster care system
looked at cortisol level, a biological measure of the stress response. Over time, the stress
response of children receiving the intervention showed better regulation and became
similar to that of children in the general population.
Principle 6: Early childhood prevention interventions should target the proximal
environments of the child
(Tolan et al., 2004; Webster-Stratton et al., 2008).
The family
environment is the most important context across all periods of early child development,
and thus parents are a major target of many early childhood interventions (Dishion et al.,
2008; Fisher et al., 2011). But as a child grows older, he or she typically spends more and
more time out of the home, perhaps attending day care, then attending preschool followed
by elementary school (Beets et al., 2009; Conduct Problems Prevention Research Group,
1999; Hawkins et al., 1999; Ialongo et al., 1999; Snyder et al., 2010). Interventions for
different age groups and targeting different types of problems should focus on the most
relevant context(s)—the home, school, day care, or a combination.
Principle 7: Positively affecting a child’s behavior through early intervention can
elicit positive behaviors in adult caregivers and in other children, improving the
overall social environment
(Fisher & Stoolmiller, 2008; Shaw et al., 2009).
Behavioral
changes in children and the adults who interact with them can be mutually self-reinforcing.
Improving the child’s family or school environment can, over time, cause the child’s social
behavior to become more positive and healthy (or pro-social); this, in turn, can elicit more
positive interactions with others and improve the social environment as a result.
Selected References
August GJ, Lee SS, Bloomquist L, Realmuto GM, Hektner JM. Dissemination of an evidence-
based prevention innovation for aggressive children living in culturally diverse, urban
neighborhoods: the Early Risers effectiveness study. Prev Sci. 2003;4(4):271-286.
B
eets MW, Flay BR, Vuchinich S, et al. Use of a social and character development program
to prevent substance use, violent behaviors, and sexual activity among elementary-sch
ool
students in Hawaii. Am J Public Health 2009;99(8):1438-1445.
Bruce J, McDermott J, Fisher P, Fox N. Using behavioral and electrophysiological measures
to assess the effects of a preventive intervention: a preliminary study with preschool-aged
foster children. Prev Sci. 2009;10(2):129140.
Catalano RF, Mazza JJ, Harachi TW, Abbott RD, Haggrety KP, Fleming CB. Raising healthy
children through enhancing social development in elementary school: results after 1.5
years. J Sch Psychol. 2003;41(2):143-164.
Conduct Problems Prevention Research Group. Initial impact of the Fast Track prevention
trial for conduct problems: II. Classroom effects. J Consult Clin Psychol. 1999;67(5):648-657.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 9
DeGarmo DS, Eddy JM, Reid JB, Fetrow RA. Evaluating mediators of the impact of the
Linking the Interests of Families and Teachers (LIFT) multimodal preventive intervention
on substance use initiation and growth across adolescence. Prev Sci. 2009;10(3):208-220.
Dishion TJ, Connell AM, Weaver CM, Shaw DS, Gardner F, Wilson MN. The Family Check-Up
with high-risk indigent families: preventing problem behavior by increasing parents’
positive behavior support in early childhood. Child Dev. 2008;79(5):1395-1414.
Fisher PA, Stoolmiller M, Gunnar MR, Burraston BO. Effects of a therapeutic intervention
for foster preschoolers on diurnal cortisol activity. Psychoneuroendocrinology. 2007;32(8–
10):892-905.
Fisher PA, Stoolmiller M, Mannering AM, Takahasi A, Chamberlain P. Foster placement
disruptions associated with problem behavior: mitigating a threshold effect. J Consult Clin
Psychol. 2011;79(4):481-487.
Fisher PA, Stoolmiller M. Intervention effects on foster parent stress: associations with
child cortisol levels. Dev Psychopathol. 2008;20(3):1003-1021.
Hawkins JD, Catalano RF, Kosterman R, Abbott RD, Hill KG. Preventing adolescent health-
risk behaviors by strengthening protection during childhood. Arch Pediatr Adolesc Med.
1999;153(3):226-234.
Hawkins JD, Kosterman R, Catalano R, Hill KG, Abbott RD. Effects of social development
intervention in childhood 15 years later. Arch Pediatr Adolesc Med. 2008;162(12):1133-
1141.
Ialongo NS, Werthamer L, Kellam SG, Brown CH, Wang S, Lin Y. Proximal impact of two
first-grade preventive interventions on the early risk behaviors for later substance abuse,
depression, and antisocial behavior. Am J Community Psychol. 1999;27(5):599-641.
Kellam SG, Brown CH, Poduska JM, et al. Effects of a universal classroom behavior
management program in first and second grades on young adult behavioral, psychiatric,
and social outcomes. Drug Alcohol Depend. 2008;95(Suppl 1):S5-S28.
Kellam SG, Wang W, Mackenzie ACL. The impact of the Good Behavior Game, a universal
classroom-based preventive intervention in first and second grades, on high-risk sexual
behaviors and drug abuse and dependence disorders into young adulthood. Prev Sci.
2014;15(Suppl. 1):S6-S18.
Kitzman H, Olds D, Cole R, et al. Enduring effects of prenatal and infancy home visiting by
nurses on children: follow-up of a randomized trial among children at age 12 years. Arch
Pediatr Adolesc Med. 2010;164(5):412-418.
Lonczak HS, Abbott RD, Hawkins JD, Kosterman R, Catalano RF. 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(5):438-447.
Shaw D, Connell A, Dishion T, Wilson M, Gardner F. Improvements in maternal depression
as a mediator of intervention effects on early childhood problem behavior. Dev
Psychopathol. 2009;21(2):417-439.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 10
Shaw DS, Dishion TJ, Supplee L, Gardner F, Arnds K. Randomized trial of a family-centered
approach to the prevention of early conduct problems: 2-year effects of the family check-up
in early childhood. J Consult Clin Psychol. 2006;74(1):1-9.
Snyder FJ, Vuchinich S, Acock A, et al. Impact of the Positive Action program on school-level
indicators of academic achievement, absenteeism, and disciplinary outcomes: a matched-
pair, cluster randomized, controlled trial. J Res Educ Eff. 2010;3(1):26-55.
Tolan P, Gorman-Smith D, Henry D. Supporting families in a high-risk setting: proximal
effects of the SAFEChildren preventive intervention. J Consult Clin Psychol. 2004;72(5):855-
869.
Webster-Stratton C, Reid MJ, Stoolmiller M. Preventing conduct problems and improving
school readiness: evaluation of the Incredible Years Teacher and Child Training Programs
in high-risk schools. J Child Psychol Psychiatry. 2008;49(5):471-488.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 11
Abundant research in psychology, human development, and other fields has shown that
events and circumstances early in peoples’ lives influence future decisions, life events, and
life circumstances—or what is called the life course trajectory. People who use drugs
typically begin doing so during adolescence or young adulthood (see “Adolescent Drug
Use”), but the ground may be prepared for drug use much earlier, by circumstances and
events that affect the child during the first several years of life and even before birth.
The first, overarching principle drawn from the
research reviewed for this resource is that
intervening early in childhood can alter the life
course trajectory of children in a positive direction.
Early childhood, considered in this book to include the prenatal period through age 8,
includes the following developmental periods:
• Prenatal Period (conception to birth)
• Infancy and Toddlerhood (birth to 3 years)
• Preschool (ages 3 through 6 years)
• Transition to School (ages 6 through 8 years)
†
†
The transition to school period is actually part of the middle childhood and early adolescence period (6 to 13
years) but is addressed separately in this book because it is a major and significant transition in the child’s
development. The middle childhood period is followed by adolescence (ages 13 to 18). The age range for the
interventions that form the basis for the principles of prevention described in this resource is prenatal
through 8 years.
Principle 1: Intervening early in
childhood can alter the life course
trajectory in a positive direction.
Adolescent Drug Use
Collection of data from the National Survey of Drug Use and Health (NSDUH) on age at
first use of illegal drugs across the U.S. begins at age 12 years, with data from 2014
indicating that 3.4 percent of 12- to 13-year-old children have used an illegal drug in the
past month (including inappropriate use of prescription drugs), 2.1 percent are current
alcohol users, and 1.1 percent are current tobacco users (CBHSQ, 2015). In 2015, NIDA’s
annual Monitoring the Future (MTF) survey of adolescent drug use and attitudes showed
that, by the time they are seniors, 64 percent of high school students have tried alcohol,
almost half have taken an illegal drug, 31 percent have smoked a cigarette, and 18 percent
have used a prescription drug for a nonmedical purpose (Johnston et al., 2016).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 12
What does the life course perspective show about risk for drug abuse and how to
prevent it?
The period of development covered in this guide is characterized by rapid orderly
progressions of normal patterns of physical, cognitive, emotional, and social development.
This development is marked by important transitions between developmental periods and
the achievement of successive developmental milestones (see “Life Transitions” and
“Developmental Milestones”). How successfully or unsuccessfully a child meets the
demands and challenges arising from a given transition, and whether the child meets
milestones on an appropriate schedule, can affect his or her future course of development,
including risk for drug abuse or other mental, emotional, or behavioral problems during
adolescence.
A variety of factors, known as
risk factors, can interrupt or
interfere with unfolding
developmental patterns in all of
these periods and, especially, in
the transitions between them.
Prevention interventions designed specifically for early developmental periods can address
these risk factors by building on existing strengths of the child and his or her parents (or
other caregivers) and by providing skills (e.g., general parenting skills and specific skills
like managing aggressive behavior), problem-solving strategies, and support in areas of the
child’s life that are underdeveloped or lacking.
Life events or transitions represent points during which the individual is in a period of
change, and they are sometimes called sensitive, critical, or vulnerable periods (Brazelton,
1992; Bornstein, 1989). Although vulnerability can occur at many points along the life
course, it tends to peak at critical life transitions, which present risks for substance abuse
as well as opportunities for intervention. Thus transitions such as pregnancy, birth, or
entering preschool or elementary school are prime opportunities to introduce skills,
knowledge, and competencies to facilitate development during those transitions.
Therefore, interventions are often designed to be implemented around periods of
transition.
The life transitions diagram points to life course periods, contexts, and transitions or life
events that together contribute to the development of the child from the prenatal period
through young adulthood. (The life course continues through to the end of life, but this
resource focuses on just the early years.)
The child’s stage of life, aspects of his or her social and
physical environments, and life events experienced
over time all contribute to the child’s physical,
psychological, emotional, and cognitive development.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 13
Life Transitions
Vulnerability to the risk factors for problems such as substance abuse can occur throughout
the life course, but it tends to peak during critical life transitions. Transitions may be
biological, such as puberty, or they may involve entering a new environmental context, such
as attending school for the first time. How a child responds and adapts to these events is
influenced by his or her cognitive, emotional, and social development at that point in time
as well as past history, family relationships, and the surrounding world. Other transitions,
such as parental divorce or military deployment of a parent, may not be predictably linked
to a child’s development, but these events or circumstances still require the child to adapt
successfully (for instance to new people or new contexts). Because of their introduction of
new potential risk factors, transitions are sometimes called sensitive, critical, or vulnerable
periods, and they are prime opportunities for preventive intervention.
The figure below illustrates the development/life course trajectory from the prenatal period
through young adulthood, indicating the periods of transition and life change that could
represent both times of risk and periods where intervention could be of greatest benefit.
Developmental periods, life course transitions, and contexts relevant to those transitions that
contribute to the development of the child from the prenatal period through young adulthood
(Kellam & Rebok, 1992).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 14
What are the major influences on a child’s early development?
The changes unfolding throughout a child’s development are influenced by a complex
combination of factors. One of them is the genes the child inherits from his or her biological
parents. Genetic factors play a substantial role in an individual’s development through the
course of life, influencing a person’s abilities,
personality, physical health, and vulnerability
to risk factors for behavioral problems like
substance abuse. But genes are only part of the
story.
Another very important factor is the
environment, or the contexts into which the
child is born and in which the child grows up.
The family/home environment is the context
that most directly influences the young child’s
early development and socialization (see
“Socialization”). This includes quality of
parenting and other parenting influences such
Developmental Milestones
Developmental milestones refer to particular physical, cognitive, social, or emotional
capabilities that are ordinarily acquired within a certain age range. For example, most
infants crawl around 9 months and walk by 12 to 15 months; most toddlers can speak one-
and two-word phrases between ages 1 and 2; and so on (see
www.cdc.gov/ncbddd/actearly/milestones/index.html). Over the course of development,
these emerging capabilities generally trigger changes in other people’s expectations and
responses—for instance, upon entering elementary school, teachers will expect children
to be able to sit and be attentive. Achieving milestones within the expected time frame is
an important signal that development is occurring in the expected manner and timeframe,
and offers protection against risk factors for substance abuse and other problems later in
development. Failure to achieve important milestones may indicate the need for early
intervention.
This does not mean that a child who is well below average on a milestone will not
eventually achieve that milestone (or will necessarily develop later problems); milestones
can be achieved later in development, albeit with greater difficulty. Part of what makes it
possible to achieve a milestone at a later time is the ability of the brain to change, adapt,
and reorganize. This type of brain activity is called plasticity, and the brain remains plastic
to some degree throughout life (Kellam & Rebok, 1992; Leighton et al., 1963; Weiss,
1949). However, very young children have the greatest neurological flexibility and
potential for learning new skills and behaviors; brain structure stabilizes with age and it
becomes increasingly difficult to alter (see “The Developing Brain, 0 to 8 Years”).
Socialization
Socialization refers to a process of
acq
uiring and internalizing the behaviors,
norms, and beliefs of the individual’s
society. It is a process that occurs across
the course of development. During the
early childhood period, both internal
processes (such as learning style,
attention, information processing) and
the sum total of the child’s social
experiences in family, school, and
community contexts affect socialization.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 15
as genetic factors and family functioning. Also, siblings, if present, can influence a child’s
development and adjustment (e.g., internalizing and externalizing behaviors and substance
use, as well as positive behaviors) (Dunn, 2005; Feinberg et al., 2013; Kramer & Conger,
2009; Pike et al., 2005). These influences may result from shared environmental
experiences and interactions with parenting and other family factors (Burt et al., 2010;
Neiderhiser et al., 2013). But conditions at home are also influenced by wider physical,
social, economic, and historical realities—such as the family’s socio-economic status and
the affluence and safety (or lack thereof) of the community in which the family lives. As the
child grows older and enters school, these wider environmental contexts influence him or
her more directly.
What follows is an overview of the developmental influences and changes taking place
during specific periods of early childhood development.
Prenatal Period
The genes, biological capacities, and innate temperament that children are born with
inform the way they interact with the environment and people in it. Development is shaped
by a combination of genetic and environmental factors (see “The Developing Brain, 0 to 8
Years.”).
Even before a child is born, the context or environment plays an important role in
development. It has long been known, for example, that if the mother smokes, drinks
alcohol, or uses other drugs during her pregnancy, these substances can enter the body of
the developing fetus and have
significant effects on the development
of the body and brain, and these effects
may become risk factors for substance
use later in the child’s life (see “Risk
and Protective Factors” for more
information). There is also emerging
evidence that both parents’ past
histories of substance use may affect
their children via changes to gene
expression (see “Epigenetics”). Also,
poor nutrition during the prenatal
period can have adverse effects on the
development of the child’s brain
(National Research Council and
Institute of Medicine, 2000; Prado &
Dewey, 2014).
Epigenetics
Recent research in the emerging field of
epigenetics, or the study of environmental
influences on the way genes are expressed,
suggests that both the mother’s and father’s past
history of substance use, even before
conception, may influence the health of their
children. Studies in experimental animals have
shown that substance use may cause changes in
gene expression in a father’s sperm and a
mother’s egg cells, which could then affect the
growth and brain development of offspring,
influencing their response to substances of abuse
(Novikova et al., 2008; Vassoler et al., 2013;
Szutorisz et al., 2014). Future studies will
determine if this also occurs in humans.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 16
The Developing Brain, 0 to 8 Years
The brain is a dense network of nerve cells (neurons) and glial cells that support the neurons
in various ways. The neurons are organized in circuits that control everything people think
and do—from learning and movement to language, sensing, feeling, and exerting control
over emotions and behaviors. The brain’s development begins soon after conception, when
cells in the embryo begin to form the basic structure of the central nervous system including
the brain and spinal cord. How it develops is influenced by genetics, aspects of the
environment such as nutrition and social interactions, and life experiences. The relative
importance of these influences shifts over the course of life, and at any point they may
interact in complex ways. For example, a particular genetic factor might impede the process
of a child’s language development; but if the child is born into a family where parents
regularly talk or read to the child, it may foster language development and act to offset
those genetic influences. Brain development is not simply the growth of new nerve cells and
formation of synaptic connections (connections between neurons). Early in life, there is an
overproduction of synaptic connections, and over the course of childhood and adolescence
a process called pruning reduces the number of those connections. Connections that are
used frequently become strengthened; those that are not are eliminated. For example,
children are born with the capacity to understand and replicate sounds of all languages;
however, over the course of development these abilities become specific to the language or
languages to which they are exposed. Thus the neural connections that would allow further
language development diminish in the middle childhood years.
Across childhood and adolescence, the cortex (the outer layer of the brain) matures at
different speeds, as measured by its overall volume, its thickness, its surface area, and other
characteristics that correspond to its functioning. Generally, areas at the back and sides of
the brain that process sensory information (e.g., vision, hearing, and all types of body
sensations) finish developing earliest, during childhood; frontal cortical areas, which handle
emotional and behavioral control and other higher order executive functions, are the last to
finish developing—only reaching maturity in early adulthood. Boys’ and girls’ brains differ in
their pattern of brain maturation, with peak changes in cortical volume and surface area
typically occurring later in boys (around age 10) than in girls (around age 8) (Raznahan et al.,
2011).
The proportional genetic and environmental influences on various aspects of brain
development are not the same across all brain regions. Recent twin studies have shown, for
example, that variations in the thickness of the frontal cortex are more attributable to
genetic factors than thickness of other areas of the cortex (Schmitt et al., 2014). Also, the
relative influence of environmental and genetic factors in brain development shifts across
the first three decades of life: The environment exerts its greatest proportional impact in
early childhood and gradually lessens, relative to genetic influences, across later childhood
and adolescence. This provides an important genetic and neurobiological rationale for
intervening in early childhood, when changes in the individual’s environment can have the
greatest long-term impact.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 17
Infancy and Toddlerhood
Once the child is born, factors that
contribute to the child’s development
include the quality of the nutrition and
health care provided by the mother and
other caregivers, the personality fit
between infant and caregivers, and the
ability of the caregivers to provide
warmth and support. The child also plays
a more active role in shaping his or her
environmental context (see “Influence is
not Just a One-Way Street”).
Influence is not Just a One-Way Street
Within moments after birth, the infant’s
personality and overall health can influence
the parent-child relationship and physical
environment in significant ways. As the child
grows older, his or her unfolding personality
and needs influence the family environment,
school environment, and wider social contexts,
which in turn exert an influence on the child
and others in the same surroundings.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 18
Over the months following birth, the child adapts to and integrates into the surrounding
world as he or she makes further developmental gains, including ongoing brain
development. Through practice, the child ideally becomes proficient at basic skills using
limited but growing sensory, motor, cognitive, and social capacities, meeting basic
milestones along the way. As the infant learns to distinguish self from others, he or she
instinctively focuses attention on the primary caregiver(s), usually parents.
For optimal positive development to occur, the primary caregiver(s) must consistently
meet the child’s needs, be nurturing, provide a predictable schedule, and provide
developmentally appropriate stimulation. The closeness of the parent-child relationship
during this early period provides a context for the child’s development and his or her
expectations about the world as well as for secure attachment to his or her caregiver(s).
Secure attachment is one of the most crucial factors leading to healthy socialization and
self-regulation, which are major protective factors against drug use and other behavioral
problems.
Preschool
Throughout early childhood, even when the child enters preschool or attends day care, the
family remains the most important context for development. Parents play a number of
roles in the development of a young child’s social, emotional, and cognitive competence,
including establishing the structure and routines for parent-child interactions; maintaining
a sensitive, warm, and responsive relationship style;
and providing instructional practices and experiences
that help the child acquire necessary developmental
skills. Development of motor abilities and language
skills are important in the preschool period,
influencing the child’s growing independence.
When a nurturing, responsive relationship does not exist, elevated levels of stress
hormones can impede a child’s healthy brain development (Debellis & Zisk, 2014;
Thompson, 2014). Moreover, when a caregiver cannot provide attention and nurturing
because of a history of trauma, chronic stress, and/or mental health problems, the child is
more likely to develop behavioral, social, emotional, or cognitive problems (Madigan et al.,
2012; Delker et al., 2014). Likewise, impaired judgment related to substance use can
reduce a parent’s ability to create a warm, supportive environment for the child (Barnard &
McKeganey, 2004; Lam et al., 2007). Child abuse and neglect, social isolation due to illness
or disability, and lack of constancy in the primary caregiver (as in the case of a child in
institutionalized care) are also linked to growth (including brain growth and neuronal
connectivity), cognitive, motor, social, and emotional problems (see for example, Behen et
al., 2009; Martins et al., 2013; McCall, 2013; Koss et al., 2014). Many of the prevention
interventions discussed in this guide are aimed at facilitating constant, nurturing,
responsive caregiving to reduce risk and prevent child behavior problems.
Throughout early childhood, even
when the child enters preschool
or attends day care, the family
remains the most important
context for development.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 19
Transition to School
As the child grows older, new transitions and associated challenges occur. A major
transition for young children is beginning elementary school. Even children who attended
preschool or had been in day care can find the rules for behavior and academic
requirements associated with elementary school difficult to adapt to and achieve.
Readiness for school is something that occurs over time with experience and practice. Early
intervention can help parents and schools assist children through this transition. Once in
elementary school, teachers can help children to adjust by providing positive classroom
management.
Selected References
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and what can be done to help? Addiction. 20
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Behen ME, Muz
ik O, Saporta AS, et al. Abnormal fronto-striatal connectivity in children with histories
of early deprivation: a diffusion tensor imaging study. Brain Imaging Behav. 2009;3(3):292-297.
Bornstein, M.H. Sensitive periods in development: structural characteristics and causal
interpretations. Ps
ychol Bull. 1989;105(2):79-197.
Brazelton TB. To
uchpoints: The Essential Reference to Your Child’s Emotional and Behavioral
Development. Read
ing, MA: Addison-Wesley Publishing Company; 1992.
Burt SA, McGue M, Iacono WG. Environmental contributions to the stability of antisocial behavior
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er time: are they shared or non-shared? J Abnorm Child Psychol. 2010;38:327-337.
Center for Behavioral Health Statistics and Quality (CBHSQ). 2014 National Survey on Drug Use and
Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration;
2015.
De Bellis MD, Zisk A. The biological effects of childhood trauma. Ch
ild Adolesc Psychiatr Clin N Am.
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Delker BC, Noll LK, Kim HK, Fisher PA. Maternal abuse history and self-re
gulation difficulties in
preadolescence. Child Abuse Negl. 20
14;38(12):2033-2043.
Dunn J. Commentary: siblings in their families. J Fam Psychol. 2005;19(4):654-657.
Feinberg ME, Solmeyer AR, Hostetler ML, Sakuma KL, Jones D, McHale SM. Siblings are special: initial
test of a new approach for preventing youth behavior problems. J A
dolesc Health. 2013;53(2):166-
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Johnston LD, O'Malley PM, Miech RA, Bachman JG, Schulenberg JE. Monitoring the Future National
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ults on Drug Use: 1975-2015: Overview, Key Findings on Adolescent Drug Use. Ann Arbor, MI:
Institute for Social Research, The University of Michigan; 2016.
Kellam SG, Rebok GW. Building developmental and etiologica
l theory through epidemiologically
based preventive intervention trials. In: McCord J, Tremblay RE, eds. Preventing Antisocial Behavior:
Interventions from Birth through Adolescence. New
York, NY: Guilford Press; 1992:162-195.
Koss KJ, Hostinar CE, D
onzella B, Gunnar MR. Social deprivation and the HPA axis in early
development. Psychoneuroendocrinology. 2014;50:1-13.
Kramer L, Conger KJ. What we learn from our sisters and brothers: for better or for worse. In Kramer
L, Conger KJ, eds. Siblings as Agents of Socialization. Ne
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Lam WK, Cance JD, Eke AN, Fishbein DH, Hawkins SR, Williams JC. Children of African-American
mothers who use crack cocaine: parenting influences on youth substance use. J
Pediatr Psychol.
2007;32(8):877-8
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Leighton DC, Harding JS, Macklin DB, Macmillan A
M, Leighton AH. The Character of Danger:
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elected Communities. Vol. 3. New York, NY: Basic Books; 1963.
Madigan S, Wade M, Plamondon A, Jenkins J. Maternal abuse history, postpartum depression, and
p
arenting: links with preschoolers’ internalizing problems. Infant Ment Health J. 2012;36(2):146-
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Martins C, Belsky J, Marques S, et al. Diverse physical growth trajectories in institutionalized
Portuguese children below age 3: relation to child, family, and institutional factors. J Pediatr Psychol.
2013;38(4):438-448.
McCall RB. The consequences of early institutionalization: can institutions be improved? - should
they? Child Adolesc Ment Health. 2013;18(4).
National Research Council and Institute of Medicine. From Neurons to Neighborhoods: The Science of
Early Childhood Development. Committee on Integrating the Science of Early Childhood
Development. Jack P. Shonkoff and Deborah A. Phillips, eds. Board on Children, Youth, and Families,
Commission on Behavioral and Social Sciences and Education. Washington, D.C.: National Academy
Press; 2000.
Neiderhiser JM, Marceau K, Reiss D. Four factors for the initiation of substance use by young
adulthood: a 10-year follow-up twin and sibling study of marital conflict, monitoring, siblings, and
peers. Dev Psychopathol. 2013;25(1),133-149.
Novikova SI, He F, Bai J, Cutrufello NJ, Lidow MS, Undieh AS. Maternal cocaine administration in mice
alters DNA methylation and gene expression in hippocampal neurons of neonatal and prepubertal
offspring. PLoS One. 2008;3(4):e1919.
Pike A, Coldwell J, Dunn JF. Sibling relationships in early/middle childhood: links with individual
adjustment. J Fam Psychol. 2005;19(4):523-532.
Prado EL, Dewey KG. Nutrition and brain development in early life. Nutrition Review.
2014;72(4):267-284.
Raznahan A, Shaw P, Lalonde F, et al. How does your cortex grow? J Neurosci. 2011;31(19):7174-
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Schmitt JE, Neale MC, Fassassi B, et al. The dynamic role of genetics on cortical patterning during
childhood and adolescence. PNAS. 2014;111(18):6774-6779.
Szutorisz H, DiNieri JA, Sweet E, et al. Parental THC exposure leads to compulsive heroin-seeking and
altered striatal synaptic plasticity in the subsequent generation. Neuropsychopharmacology.
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Thompson RA. Stress and Child Development. Future Child. 2014 Spring;24(1): 41-59.
Vassoler FM, White SL, Schmidt HD, Sadri-Vakili G, Pierce RC. Epigenetic inheritance of a cocaine
resistance phenotype. Nat Neurosci. 2013;16(1):42-47.
Weiss P. The biological basis of adap
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Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 21
Research over the past three decades has identified many factors that can help differentiate
individuals who are more likely to abuse drugs from those who are less likely to do so
(Catalano et al., 2011; Hawkins et al., 1992). Risk factors are qualities of a child or his or her
environment that can adversely affect the child’s developmental trajectory and put the
child at risk for later substance abuse or other behavioral problems. Protective factors are
qualities of children and their environments that promote successful coping and adaptation
to life situations and change. Protective factors are not simply the absence of risk factors;
rather, they may reduce or lessen the negative
impact of risk factors (Cowen & Work, 1988;
Garmezy, 1985; Hawkins et al., 1992; Rutter,
1985; Werner, 1989).
All children will have some mix of risk and protective factors. An important goal of
prevention is to change the balance between these so that the effects of protective factors
outweigh those of risk factors.
Both risk and protective factors may be internal to the child (such as genetic or personality
traits or specific behaviors) or external (that is, arising from the child’s environment or
context), or they may come from the interaction between internal and external influences.
What are some important early childhood risk factors for later drug use?
Some factors that powerfully influence a child’s risk for later substance abuse and other
problems have their strongest effects during specific periods of development. Important
examples include:
Prenatal Period
Maternal smoking and drinking can af
fect a developing fetus and may result in altered
growth and physical development and cognitive impairments in the child (See “Pregnancy
Matters: Use of Substances and Their Effects During Pregnancy”).
Principle 2: Intervening early in
childhood can both increase protective
factors and reduce risk factors.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 22
Pregnancy Matters: Use of Substances and Their Effects During Pregnancy
Exposure to alcohol, tobacco, and other drugs of abuse during the prenatal period can
affect children throughout their lifetime. Substances taken during pregnancy can cross
the placenta, exposing the developing brain of the fetus to their effects. Examples of the
effects of substance use during pregnancy include the following:
• Smoking during pregnancy has been linked to increased risk for slowed fetal
growth and low birth weight, stillbirth, pre-term birth, infant mortality, Sudden
Infant Death Syndrome, and respiratory problems.
• Using alcohol during pregnancy can cause miscarriage, stillbirth, and a range of
lifelong disorders for the child known as Fetal Alcohol Spectrum Disorders
(FASDs). FASDs can lead to physical, cognitive, and behavioral problems—for
example, facial abnormalities; attention problems and hyperactive behavior;
learning disabilities; poor reasoning and judgment skills; and problems with the
heart, kidney, or bones.
• The use of illicit drugs, such as cocaine, heroin, and marijuana, during
pregnancy can have a variety of adverse effects on children ranging from low
birth weight to developmental problems related to behavior and cognition, such
as impaired attention, problems with language development and learning, and
behavior problems.
• The use of some types of prescription drugs during pregnancy may also have an
impact on the child. Babies of mothers who chronically take opioid medications
prescribed for pain or who are abusing those medications may be born with a
physical dependency, causing withdrawal—a condition called Neonatal
Abstinence Syndrome (NAS), which can require prolonged hospitalization of the
infant and medication to treat.
The full extent of the consequences of substance use in pregnancy are not known
because many confounding individual, family, and environmental factors such as
nutritional status, extent of prenatal care, and socio-economic conditions make it
difficult to determine the direct impact of prenatal substance use on the child.
Therefore, abstinence is the best prevention.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 23
Infancy and Toddlerhood
Having a difficult temperament in
infancy may set the stage for the child
having trouble with self-regulation
later, as well as create challenges for
the parent-child relationship (see “A
Child’s Temperament”).
Insecure attachment during the
child’s first year of life can cause a
child to be aggressive or withdrawn,
fail to master school readiness skills,
and have difficulty interacting with
adults or other children (see
“Attachment”).
Uncontrolled aggression when a
child is a toddler (2 to 3 years) can
lead to problems when he or she
enters preschool, such as being
rejected by peers, being punished by
teachers, and failing academically.
Preschool
Lack of school readiness skills such as failure to have learned colors, numbers, and
counting will put a child at a disadvantage in a classroom environment, setting the stage for
poor academic achievement.
Transition to School
Poor self-regulation can lead to frustration and constant negative attention on the child
by peers and teachers at school.
Lack of classroom structure in the school environment can lead to additional social and
behavioral problems in children who have trouble switching from one activity to another.
A Child’s Temperament
All children are born with a unique temperament, or
personality characteristics (Goldsmith et al., 1987)
that make them easier or harder to care for. For
example, babies who are easy to manage, adapt
well to routines, and are responsive to parent care
tend to elicit positive parenting behaviors, which
will strengthen a growing, mutually satisfying
parent-child relationship. On the other hand, some
babies respond to their environment with arousal
and distress; they may cry a lot, fuss when being
changed and fed, and are not soothed by holding
and rocking. These highly reactive infants are more
likely to elicit parental frustration, impatience, and
avoidance or neglect, which can potentially escalate
into a pattern of negative family dynamics
(Kochanska & Kim, 2013; Lee & Bates, 1985). These
natural behavioral tendencies are the focus of early
interventions for parents. Such interventions
nurture appropriate expectations of infants by
parents, strengthen positive parenting practices,
and help parents to cope with frustrating situations.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 24
Any Developmental Period
Other risk factors can affect a child in any developmental period. Some important ones are:
Stress (Institute of Medicine and National Research Council, 2012; Masten, 1989; McEwen,
2010). All children experience stress at some point, and in fact a certain amount of stress
helps young children develop skills for meeting challenges and coping with setbacks that
inevitably occur in life. But chronic stressors like family poverty and stress that is intense
or prolonged—such as a parent’s mental health problems or a lingering illness—can
diminish a child’s ability to cope. These types of stress can even interfere with proper
development, including brain development, and aspects of physical health like proper
functioning of the immune system (Brown et al., 2009). This is particularly true of children
who have experienced the extreme stress of maltreatment, such as abuse or neglect, by
parents or caregivers (see “The Special Case of Abuse and Neglect”). Some children who
experience a lot of stress early in life, even during the prenatal period, are more susceptible
to the effects of later stressful life circumstances than other people (Raposa et al., 2014;
Shonkoff et al., 2012; Turner & Lloyd, 2003).
Attachment
Attachment is the natural bond that develops between parent and child (Ainsworth et al.,
1978; Bowlby, 1969; Bowlby, 1982). Usually this bond is positive and secure, but when
children fail to develop secure attachments to their parents, they may perceive that the
world is unsafe and eventually mistrust other people and distrust their own abilities to
master the environment.
Attachment may be insecure due to particular experiences that get in the way of forming a
secure bond, to specific personality characteristics of the parent and/or child, or to poor
“fit” between characteristics of the parent and child. For example, an easy-going infant may
react more calmly to a first-time parent’s clumsy attempts at feeding, changing, and bathing
him, whereas a more sensitive child might react with crying and other behaviors that could
cause the parent to feel insecure about his or her capacity to parent. This in turn could
affect interactions that promote attachment security (e.g., sensitive, contingent-responsive
parenting). However, this is not deterministic. Good quality parenting is possible even when
parent/child characteristics and experiences do not match up.
Early problems with attachment can lead to problems like acting out in school, poor
academic achievement, and social isolation during the transition to elementary school
(Fearon et al., 2010; Kochanska & Kim, 2012). Later on, during puberty, the transition to
middle school, and adolescence, children with insecure attachment may associate with
peers who exhibit problem behaviors and experiment with behaviors such as delinquency,
substance use, and sexuality (Schindler & Bröning, 2015).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 25
Parental substance use: Parental substance use—including smoking, drinking, illicit drug
use, and prescription drug abuse—can affect children both directly and indirectly.
Substances used by a mother during pregnancy can cross the placenta and directly expose
the fetus to drugs (see “Pregnancy Matters: Use of Substances and Their Effects During
Pregnancy”), and substances can pass to a nursing infant through breast milk. When
parents smoke in the home, it can also expose children to secondhand smoke, putting them
at risk for health and
behavioral problems (see
“Secondhand Smoke”), as well
as increasing children’s
likelihood of smoking when
they grow older (Leonardi-Bee
et al., 2011).
Parental substance use can also
impact the family environment
by giving rise to family conflict
and poor parenting, which
could increase risk for child
abuse and neglect and
involvement with the child
welfare system (National
Research Council and Institute
of Medicine, 2009). Poor family
functioning can increase the
risk for multiple problem
behaviors in children and
adolescents, including risk for
substance use and abuse
The Special Case of Child Abuse and Neglect
Children who have experienced abuse or neglect by parents or caregivers are at greater risk
for substance abuse and other mental, emotional, and behavioral problems than other
children. Moreover, child maltreatment is associated with family-level risk factors, such as
poor parenting skills, parental substance abuse and mental illness, and context-specific risks
such as poverty (National Research Council and Institute of Medicine, 2009). The most
straightforward way to eliminate the negative effects of child abuse and neglect is to prevent
its occurrence. One exemplary preventive intervention that takes this proactive approach is
the Nurse Family Partnership (NFP) program, described in Research-Based Early Intervention
Drug Abuse Prevention Programs. Other interventions are designed to address issues in
children who may have already been subject to abuse; one example is the Multidimensional
Treatment Foster Care Program for Preschoolers (MTFC-P; also discussed in Research-Based
Early Intervention Drug Abuse Prevention Programs), which addresses developmental issues
among maltreated foster preschoolers.
Secondhand Smoke
According to the surgeon general, there is no safe
level of exposure to secondhand smoke (HHS, 2006).
When children are exposed to it, they can develop
the same kinds of health problems seen in smokers
themselves. Secondhand smoke exposure in
childhood is associated with upper and lower
respiratory tract illnesses and asthma, as well as
infection and tooth decay; it is the leading
preventable cause of ear infection; and it is
recognized as the most common preventable cause
of Sudden Infant Death Syndrome (SIDS) (Zhou et al.,
2014). Also, some components in secondhand smoke,
such as carbon monoxide, are neurotoxic. Because
children’s brains are still developing, exposure to
these chemicals can alter developmental trajectories
and have long-lasting effects. Secondhand smoke
exposure in children is linked to impaired executive
brain function, which manifests most clearly as
behavioral problems and an increased risk of ADHD
(Pagani, 2014; Padrón et al, 2015).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 26
(Aarons et al, 2008). Children with a family history of drug abuse also may have increased
genetic risk for substance use (Kendler et al., 2003; Young et al., 2006), often manifested in
combination with family or other environmental risk factors (Enoch, 2012). Children can
learn about substance use from a very young age, especially if exposed to parental
substance use and abuse (Noll et al, 1990). However, children are less likely to smoke,
drink alcohol, or use other drugs when parents are clear that they do not want their
children to do so, even if they use substances themselves (Jackson & Dickinson, 2006).
Emergent mental illness. Many mental illnesses have symptoms that can emerge during
childhood and can increase risk for later drug abuse and related problems. For example,
anxiety disorders and impulse-control disorders (such as ADHD) begin their onset prior to
11 years of age, on average (Kessler et al., 2005), but frequently symptoms may appear in
early childhood. Symptoms associated with impulse-control disorders, such as aggressive
disruptive behavior, as well as those associated with affective and psychotic disorders all
increase the risk of substance use disorders and related problems in adolescence
(Maslowsky et al, 2014; Gregg et al., 2007). (See “Drug Abuse and Mental Illness.”)
If not successfully addressed when they initially present themselves, early risk factors and
associated negative behaviors can lead to greater risks later in childhood and in
adolescence, such as academic failure and social and emotional difficulties, all of which put
an individual at increased risk for substance abuse.
What if a child has multiple risk factors?
Research has shown that the more risk factors a child has or is exposed to, the more likely
it is that he or she will experience problems (see “Accumulated Risk”) Unfortunately, many
risk factors are related and tend to cluster together. For example, child maltreatment is
associated with other family-level risk factors, such as poor parenting skills and parental
substance abuse and mental illness (National Research Council and Institute of Medicine,
2009); ongoing maltreatment also results in developmental delays, which can compound a
child’s risk for later behavioral and emotional problems.
Substance Abuse and Mental Illness
The relationship between substance abuse and other psychiatric disorders can be
complex. Although the causal relationships are not fully understood, it is likely that
shared genetic or biological risk factors give rise to both substance use disorders and
mental illness and that symptoms of one may influence the development of the other,
partly because they may affect the same or related brain circuitry and processes—for
example, memory and neuroplasticity (Pittenger, 2013). Thus, just as early manifestations
of mental illness increase the risk of later substance use, many childhood risk factors for
substance use also may increase risk for later appearance of other psychiatric and
behavioral problems, including conduct disorder, depression, and delinquency. And
substance use during adolescence may also precipitate or affect the course of mental
illness—for instance, adolescent use of marijuana may trigger psychosis in individuals
with a genetic vulnerability for schizophrenia (Di Forti et al., 2012).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 27
Another example is poverty, which reduces a family’s material resources for providing
good food, medical care, and child care and thus is often linked with other risk factors such
as premature birth and poor nutrition (Gershoff et al., 2003). Poverty may also be linked to
problems with attachment, because it
reduces the time and energy parents can
devote to interacting with their child. As
a result, children from impoverished
families may encounter multiple risk
factors in a variety of developmental
contexts.
However, individuals differ widely in how vulnerable they are to being affected by specific
risk factors. Parents and educators should keep in mind that most young people, even those
with risk factors for substance abuse, do not actually develop drug problems or other
mental, emotional, or behavioral problems. Resilient children may even have a large
number of risk factors but still not experience difficulties (see “Resilience”).
Parents and educators should keep in mind
that most individuals, even those with risk
factors for drug abuse, do not actually develop
substance abuse or other mental, emotional,
or behavioral problems.
Accumulated Risk
It is possible that children whose personal
characteristics and family and school
environments are highly protective can still
succumb to the effects of accumulated risk if
they live in areas with high levels of risk, such
as the accumulated stress associated with living
in a violent environment. There is as yet no
direct evidence supporting this principle in the
age group considered in this guide, but
evidence from a study on risk and protective
factors among a sample of 6th- through 12th-
grade students in a five-state survey pointed to
the existence of a threshold over which the
ability to tolerate risk diminishes. Youth with
highest levels of risk factors exhibited increased
prevalence rates of problem behaviors, even
when they had high levels of protective factors
(Pollard et al., 1999).
Resilience
A major conclusion from research
on risk and protective factors
among children is that there are
some children who, despite having
a significant number of risk factors,
do not develop problem behaviors.
Intervention developers and
researchers use findings from
protective factor and resiliency
research to inform their decisions
about what child, parent, and
other resources and skills should
be addressed through early
childhood prevention
interventions (Masten, 2011;
Masten 2012).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 28
What are some important protective factors that can offset risk factors?
As with risk factors, certain protective factors are important during particular
developmental periods:
• Prenatal Period: Good maternal nutrition is important for the developing fetus, as
it can reduce the chances for nutrient-related birth defects (such as spina bifida)
and can increase the likelihood that the child will have normal birth weight.
• Infancy and Toddlerhood: Parents who are highly responsive to their infant set the
stage for strong parent-child attachment.
• Preschool: Increasing behavioral control in the preschool years improves social
competence across the transition to elementary school.
• Transition to School: School readiness supports mastery of basic concepts (colors,
numbers, letters, pre-reading) during kindergarten, setting the stage for academic
success throughout the school years.
Protective factors, like risk factors, may be either internal to the individual child or may be
qualities of their contexts, including family, school, and community. Internal factors that
offer protection across all ages include intelligence and easy temperament (i.e., adapting
well to eating and sleeping schedules and to other new experiences, as well as a generally
positive mood) (Masten, 2004; Masten, 2001). Children with an easy temperament are able
to make positive adaptations to a variety of situations and may thereby relax parents who
are stressed. They may be less susceptible to the impact of parents who have other risk
factors, such as being highly disorganized, being overly organized and scheduled, or having
a negative mood. (The mix of temperaments among family members and how well they “fit”
or match onto one another can greatly influence family climate and functioning.)
External factors important in building a context for healthy development across childhood
(Masten, 2004; Masten, 2001) include parenting that includes warmth, consistency, age-
appropriate expectations, praise for accomplishments (e.g., using the toilet), and
consistent routines and rules. When providing such an environment does not come
naturally to parents, prevention interventions can help them to build the knowledge and
skills important for healthy development and the prevention of subsequent problem
behaviors such as drug abuse.
Throughout childhood, both at home and at school, it is also important that children be
provided both opportunities for social interaction with peers—as playing with other
children promotes healthy socialization—and opportunities for physical exercise.
Physical activity promotes not only physical health but also cognitive and brain
development, including the development of executive control (Hillman et al., 2014;
Chaddock-Heyman et al., 2014).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 29
Similar to risk factors, protective factors tend to cluster. For example, sensitive, responsive
parenting tends to occur along with other environments that promote good social
interactions with peers, school readiness, and behavioral control. Generally, an
accumulation of protective factors predicts positive outcomes. But just as having many risk
factors does not make substance abuse inevitable, having many protective factors does not
ensure an absence of problems.
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Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 33
The theoretical rationale for intervening in early childhood is that modifying internal and
external risk and protective factors such as those discussed in the previous chapter can
influence intermediate or proximal outcomes such as academic and other achievements;
effective learning, competence, and skill development; and effective self-regulation. This in
turn may reduce the exposure to drugs and the desire to use them during adolescence (see
“Logic Model for Intervening in Early Childhood to Prevent Drug Abuse,”).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 34
Following this rationale (or logic model), prevention
researchers have developed a large number of early
childhood intervention programs, and ample evidence
shows that they work. Some studies that followed
participants as far as late adolescence or young
adulthood have shown positive, long-term effects
(including reduced substance use) from interventions
that targeted poor parenting skills and other external
or internal risk factors during childhood (for an
example, see “Intervening to Reduce Risk for Families
and Children”).
Some of these early interventions have also been
found to prevent a wide range of other negative
behaviors and promote a wide range of positive
behaviors not specifically targeted by the intervention.
(See “Intervening Early Can Have Long-Term Effects
on a Wide Array of Behaviors.”) In some cases, studies
have shown that early childhood intervention even affected children’s biological
functioning, such as their sensitivity to stress.
Principle 3: Intervening early in
childhood can have positive
long-term effects.
Principle 4: Intervening in early
childhood can have effects on a
wide array of behaviors, even
behaviors not specifically
targeted by the intervention.
Principle 5: Early childhood
interventions can positively
affect children’s biological
functioning.
Intervening to Reduce Risk for Families and Children
Prevention interventions have been shown to alter risk factors for families and children. For
example, first-time, low-income mothers who received an intervention including home
visits during pregnancy and the first two years of life (the Nurse Family Partnership,
described in Research-Based Early Intervention Substance Abuse Programs) had fewer child
maltreatment reports involving them or their children 15 years after birth than mothers
who did not receive home visits (Eckenrode et al., 2000). In another study, this home
visiting intervention significantly reduced role impairment of mothers due to alcohol or
substance use (i.e., impaired functioning with family members, with coworkers, and with
friends) (Olds et al., 2010). For biological risk, a substance abuse prevention intervention for
adolescent African American rural youth and their families (Strong African American
Families), designed to strengthen family interactions, was found to be protective for
children with genetic risk for initiating high-risk behaviors (Brody et al., 2009).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 35
Intervening early can have long-term effects on a wide array of behaviors
Intrapersonal
Increased
Child health
Olds et al., 1986; Olds et al., 1994
Normalization of cortisol levels
Fisher et al., 2007
Language development and
cognitive function
Olds et al., 2002a; Olds et al., 1994; Lunkenheimer et al.,
2008
Self-regulation (emotional and
behavioral control)
Hawkins et al., 2005; Conduct Problem Prevention
Research Group, 2002; Lunkenheimer et al., 2008; Reid
et al., 1999; Reid et al., 2007
Pro-social behavior
Catalano et al., 2003; Washburn et al., 2011
Social competence
Conduct Problem Prevention Research Group, 2002;
Webster-Stratton et al., 2008; August et al., 2002; Tolan
et al., 2004
Age at first sexual experience
Lonczak et al., 2002
Decreased
Irritability as baby
Olds et al., 1986
Attention deficit hyperactivity
disorder (ADHD)
Tolan et al., 2004
Internalizing behaviors and
disorders (depression, anxiety)
Hawkins et al., 2005; Shaw et al., 2009; Conduct
Problem Prevention Research Group, 2002; Izzo et al.,
2005; Dolan et al., 1993; Barrera et al., 2002
Early aggressive behavior
Stoolmiller et al., 2000; Tolan et al., 2004; Tolan et al.,
2009; August et al., 2001; August et al., 2003; Dolan et
al., 1993; Kellam et al., 1994; Reid et al., 1999
Externalizing behaviors and
disorders (aggression, anti-
social behavior, and conduct
problems)
Catalano et al., 2003; Reid et al., 2007; Webster-
Stratton et al., 2008; Reid et al., 1999; Kellam et al.,
2008; Shaw et al., 2009; Kellam et al., 1994; Petras et
al., 2008; Barrera et al., 2002; Dishion et al., 2014
Delinquent, violent, and
criminal behaviors
Hawkins et al., 1999; Beets et al., 2009
Driving under the influence of
alcohol
Haggerty et al., 2006
Likelihood of selling drugs
Hawkins et al., 2005
Teen pregnancy
Lonczak et al., 2002
Lifetime sexual partners
Hawkins et al., 1999; Olds et al., 1998; Beets et al., 2009
Sexually transmitted infection
(STI)
Lonczak et al., 2002
Initiation of tobacco, alcohol
and/or other drug use/abuse
Beets et al., 2009; Degarmo et al., 2009; Storr et al.,
2002; Wang et al., 2009; Hawkins et al., 1999; Furr-
Holden et al., 2004
Alcohol, tobacco, and other
drug use
Brown et al., 2005; Kellam et al., 2008; Furr-Holden et
al., 2004; Izzo et al., 2005; Beets et al., 2009; Hawkins et
al., 1999
Substance abuse disorders
Kellam et al., 2008
Suicidal ideation and attempts
Hawkins et al., 2005; Wilcox et al., 2008
Any psychiatric diagnosis
Kellam et al., 2008
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 36
Family
Increased
Maternal prenatal and perinatal care
Olds et al., 1986; Olds et al., 1994
Maternal concern, support, nurturing,
and monitoring for the child
Olds et al., 1986; Lunkenheimer et al.,
2008; Reid et al., 1999; Tolan et al., 2004
Family problem-solving
Degarmo et al., 2009
Proactive family management
August et al., 2003
Parent involvement
Reid et al., 1999
Maternal graduation rates
Olds et al., 1988
Maternal work history
Olds et al., 1988
Decreased
Prenatal smoking
Olds et al., 1986
Subsequent pregnancies
Olds et al., 1988; Olds et al., 1997
Child accidents and poisonings
Olds et al., 1986; Olds et al., 1994
Child abuse and neglect
Olds et al., 1986; Olds et al., 1994; Olds et
al., 1997; Eckenrode et al., 2000
Domestic violence
Olds et al., 2004
Parental/caregiver stress
August et al., 2003; Fisher & Stoolmiller,
2008
Maternal depression
Shaw et al., 2009
Maternal role impairment due to
substance use
Olds et al., 1997; Olds et al., 2010
School/Work
Increased
Emphasis on social-emotional teaching
Webster-Stratton et al., 2008
Teacher reported increase in social skills
Reid et al., 1999
Academic achievement (reading and
math)
Snyder et al., 2010; Catalano et al., 2003;
Tolan et al., 2004; Tolan et al., 2009; Gunn
et al., 2005; August et al., 2001; Dolan et
al., 1993; Hawkins et al., 2005
Cooperative, team learning style
O’Donnell et al., 1995
School competence, socialization to school
context
August et al., 2001; August et al., 2003
Commitment to school, school bonding
Catalano et al., 2003; Hawkins et al., 1999
High school completion
Kellam et al., 2008; Hawkins et al., 2005
College attendance
Hawkins et al., 2005
Employment
Hawkins et al., 2005
Time at present job
Hawkins et al., 2005
Decreased
Criticism from teachers
Webster-Stratton et al., 2008
Disruptive behavior
August et al., 2003
School absenteeism
Snyder et al., 2010
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 37
Service Use
Increased
Awareness of community services
Olds et al., 1986
Decreased
Social service use (Temporary Assistance to
Needy Families; Aid to Families with Dependent
Children; other)
Olds et al., 1988; Olds et al., 1997;
Olds et al., 2010; Poduska et al.,
2008
Special education
Poduska et al., 2008
Child Protective Services
Eckenrode et al., 2000
Mental health and drug abuse services
Izzo et al., 2005; Poduska et al.,
2008
Criminal justice involvement
Olds et al., 1998; Eddy et al., 2003;
Poduska et al., 2008
What contexts do early childhood interventions target?
Prevention interventions not only support children’s development directly but also support
the development of skills and resources of those who care for children in their most
important primary contexts—or what is sometimes called their proximal environments.
The proximal environment during very early
development is the family, so prevention
interventions for the prenatal through infancy
and toddlerhood periods often focus on the
parents. When providing an environment that
supports healthy early development does not come naturally to new parents, prevention
interventions can help them to build the necessary knowledge and skills. Family
interventions may be delivered in the home, but that is not universally the case; some may
be delivered in social service, community health, or educational settings.
The family remains the most important proximal environment for children, but as a child
grows and develops, other contexts outside the family become increasingly important as
well. The classroom is an important environment during the preschool and elementary
school years, and interventions may focus on things like improving school climate,
resources, and policies as well as enhancing teachers’ skills and parent-teacher
communication. Changing classroom environments from those that react to problem
behavior to those that encourage pro-social behavior can be achieved through supporting
teacher training in constructive classroom management strategies (see “School
Interventions”).
Principle 6: Early childhood prevention
interventions should target the
proximal environments of the child.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 38
Some interventions address multiple contexts such as family and school, with emphasis on
communication and collaboration between the two environments, thereby making a
consistent prevention effort across
contexts to affect the target population(s)
of the intervention. In fact, this is a
primary strategy of interventions for
children 3 years of age and older.
Even when children are progressing along the normal course of physical, cognitive, social,
and emotional development and achieving age-appropriate milestones, improvements in
their proximal environments can further their development.
Do early childhood interventions target all children or just those at highest risk?
It depends on the type of intervention. Universal interventions are delivered to everyone in
the population regardless of risk—for example, all children in a preschool or first-grade
classroom or all children in a community. Selective interventions are delivered to groups of
children who are at risk due to some factor they have in common—for example, children
entering elementary school with a low level of self-regulation or ability to pay attention,
children living in a high poverty or crime area, or children in the foster care system.
‡
‡
An additional category, indicated interventions, has been defined by the Institute of Medicine (Institute of
Medicine (1994). Reducing Risks for Mental Disorders. Washington, DC: National Academy Press) but is not
relevant to early childhood. In the context of substance abuse prevention, indicated interventions are for
individuals who already exhibit drug use but do not meet criteria for drug abuse or addiction.
Principle 7: Positively affecting a child’s
behavior through early intervention can elicit
positive behaviors in other people, improving
the overall social environment.
School Interventions
Programs targeting children making the transition to elementary school focus on building a
repertoire of positive competencies including academic, self-regulation, and social skills. For
example, tutoring, especially in reading, is one important focus of prevention programs
because reading difficulties during the early elementary years is a strong risk factor for
school failure and later drug use. Prevention intervention programs also target social skills
that affect the children’s relationships with peers and adults outside the family. For
example, some approaches used in programs that address social skills development include
positive behavior teams, group practice, playground and free play monitoring, and
rewarding good behaviors. Incorporating skills development into the natural environment of
children allows them to practice these skills with peers. Another frequently used strategy for
these interventions is training teachers in classroom management strategies. This approach
provides teachers with both the skills for managing children’s behaviors and activities for
teaching children to manage their own behaviors and emotions, thereby helping children
develop self-regulation. Also, approaches that draw on mindfulness-based strategies (e.g.,
meditation, yoga, martial arts) are being developed and tested for their potential to
enhance self-regulation.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 39
Some interventions target more than one level of risk. For example, within a universal
intervention, screening can be provided to determine who has more severe problems and
risks, and then additional services can be provided to those most in need based on that
screening. Such programs are called tiered, because some people progress from one level of
intervention to another.
§
(Research-Based Early Intervention Substance Abuse Prevention
Programs reviews universal, selective, and tiered programs.)
What are some characteristic features of early childhood interventions?
Specific characteristics of early childhood intervention programs are generally related to
the developmental period of the child, the specific risk to be addressed, and the people with
whom the child interacts in his or her proximal environments. Interventions are generally
timed to coincide with the transitions between life course periods, because changes
occurring within and around the child during these transitions present particular risk
factors, as well as opportunities for enhancing protective factors. (See “Risks Addressed
Through Specific Age-Appropriate Strategies.”)
Risks Addressed Through Specific Age-Appropriate Strategies
Risk
Intervention Strategy
Prenatal
Maternal substance use before and
during pregnancy
Counseling through primary care and
referral to treatment
Inadequate prenatal care
In-home nurse visits
Infancy and
Toddlerhood
Inappropriate expectations for children
Parenting class on child development
Harsh discipline
Parenting class on managing child behavior
Insecure attachment
Parent class on developing a warm,
supportive relationship
Preschool
Aggressive behavior
Parent and teacher classes on setting limits
and boundaries
Poor emotional control
Preschools that teach social-emotional
learning
Delayed school readiness
Preschool programs that highlight basic
math and language concepts
Elementary
School
Behavioral problems in the classroom
Training teachers on classroom
management
Academic problems
Academic tutoring
Child acting out at school
Developing collaborative relationships
between school and home
Poor social skills
Peer social groups
§
Universal interventions do not group high-risk participants, avoiding an environment in which those at
elevated risk are set apart or stigmatized by their status. Moreover, many selective and tiered interventions
more directly address the problems that a population is likely to encounter, however these interventions
carefully consider such issues as stigma and the risks (e.g., modeling of negative behaviors) and benefits of
grouping individuals from a subpopulation.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 40
Prenatal Period, Infancy, and Toddlerhood
Prevention interventions for the prenatal period and infancy usually focus on very young
mothers and families who are at risk due to poverty. The goal is to foster a healthy
pregnancy, healthy development of mothers and their children, and a healthy parent-child
relationship. Specific programs differ, but they commonly screen mothers for drug use,
instruct them in good health care practices, and teach them how to connect to appropriate
community services. Programs typically focus on mother-child bonding, using consistent
discipline, setting an example of pro-social behavior, and getting the child ready for
preschool. Involvement of the father is often encouraged as well.
Some programs access mothers at home during the prenatal period. For example, in order
to support mothers, nurse visitors may provide extensive one-on-one instruction during
visits (Olds, 2002b). Other programs access mothers and their children through services
for low-income families. This strategy supports finding mothers and children in need,
assessing their needs, and referring them to available services and programs that meet
those specific needs (Shaw et al., 2006).
Preschool
Similar to programs for younger age groups, programs during the preschool period address
the well-being of both caregivers and children and the quality of their relationship,
primarily through teaching pro-social parenting practices. Early disruptive behaviors of
children are addressed in order to prevent escalation of these behaviors, promote better
parent-child bonding (Webster-Stratton et al., 2008), and help the child learn positive ways
of relating to others. Preschool programs can
incorporate much of the same content as
programs for younger age groups (for example,
encouragement of pro-social child behavior and
consistent contingent-responsiveness and non-
abusive limit setting) but within very different
contexts (such as school) and with children who
have a wide variety of risk factors.
Preschool is a point in time when many children are at risk for or entering child protective
placements (Child Welfare Information Gateway, 2013), and these children are at increased
risk for multiple problems early and later in life. Thus some interventions specifically
target foster parents and children. For example, in the Multidimensional Treatment Foster
Care Program for Preschoolers (MTFC-P), maltreated foster children receive individualized
services in the home, a preschool setting, and a therapeutic child play group; and foster
parents are given training to ensure that they are properly equipped to care for children
who may come to them with symptoms of severe stress and unusually difficult behavior
challenges.
Core elements of a school-based
early childhood intervention include
training teachers to establish clear
rules and rewards for compliance,
teach interactively, and promote
cooperative learning in small groups.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 41
Transition to School
A significant target of programs aimed at the transition to elementary school is creating
strong collaborative ties between families and schools. Evidence indicates that such links
facilitate children’s adjustment to school, academic achievement, pro-social peer
friendships, and self-regulation. A notable characteristic of programs targeting this period
of development is the use of interactive techniques such as role-playing, guided play
sessions, and small-group practice; research has demonstrated that interactive techniques
are more successful than lecture and information only (Tobler, 2000).
A number of programs focus on improving communications between parents and teachers
and on providing parents with information and strategies for helping their child cope with
the structure and behavioral expectations of the classroom and how to facilitate positive
peer interactions.
Research shows that parents can help their children develop skills, competencies, and
knowledge specific to the school transition and thereby promote a child’s school success.
The elementary school is also a focus of interventions to develop children’s school
competencies. At the heart of these programs are activities that build a repertoire of
positive academic, self-regulation, and social skills. Programs may include tutoring—
especially in reading, as reading difficulties in early elementary school is a risk factor for
ongoing academic problems and later school failure and drug use. Even if they target
similar outcomes, programs may use different strategies: For example, social skills
development can be approached through positive behavior teams (seating children with
social or behavioral problems with more competent children) (Ialongo et al., 1999), group
practice, playground and free-play monitoring, or rewarding of good behaviors.
Teachers are also a focus of interventions for this developmental stage. In such programs,
teachers are frequently trained in classroom management strategies. Core elements of a
school-based early childhood intervention include training teachers to establish clear rules
and rewards for compliance, teach interactively, and promote cooperative learning in small
groups. Such an approach is designed to provide teachers with both the skills for managing
child behavior and activities for teaching children to manage their own emotions and
behaviors, thereby helping children develop self-regulation.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 42
How does changing the behavior of parents and teachers help children?
In programs that target multiple actors (such as parents and teachers, or parents and
children), the program activities for one actor often reinforce those of another. For
example, parents who are taught to respond with consistency and a matter-of-fact, warm
tone when their child breaks a rule are likely to elicit a positive change in child behavior.
Thus, a program to reduce aggressive behavior in children entering school could include
activities and training in classroom management for teachers and instruction in supportive,
consistent, contingent-responsive parenting strategies for parents and other caregivers, as
well as child-oriented program components aimed at increasing the child’s attention and
self-regulation within the classroom environment.
Behavioral changes in children and the adults who interact with them can be mutually
reinforcing. By positively influencing the child’s family or school environment, child
behavior can, over time, become more pro-social; this, in turn, can elicit more positive
interactions with caregivers and peers, and thereby improve the social environment.
Who benefits the most from early childhood interventions?
While most children and families benefit from interventions, children at increased risk for
later substance abuse due to factors such as early aggressive behavior, poor emotional
control, or extreme poverty, generally benefit the most from early childhood interventions.
In addition to children, there is evidence that mothers benefit from the parenting
interventions. For example, several studies have shown positive effects on maternal
depression, substance use, education, and career attainment.
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August GJ, Lee SS, Bloomquist L, Realmuto GM, Hektner JM. Dissemination of an evidence-based
prevention innovation for aggressive children living in culturally diverse, urban neighborhoods: the
Early Risers effectiveness study. Prev Sci. 2003;4(4):271-286.
August GJ, Realmuto GM, Hektner JM, Bloomquist ML. An integrated components preventive
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Barrera M, Jr, Biglan A, Taylor TK, et al. Early elementary school intervention to reduce conduct
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Brody GH, Chen YF, Beach SR, Philibert RA, Kogan SM. Participation in a family-centered prevention
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Brown EC, Catalano RF, Fleming CB, Haggerty KP, Abbott RD. Adolescent substance use outcomes in
the Raising Healthy Children project: a two-part latent growth curve analysis. J Consult Clin Psychol.
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through annual family check-ups in early childhood: intervention effects form home to early
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Fisher PA, Stoolmiller M, Gunnar MR, Burraston BO. Effects of a therapeutic intervention for foster
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Fisher PA, Stoolmiller M. Intervention effects on foster parent stress: associations with child
cortisol levels. Dev Psychopathol. 2008;20(3):1003-1021.
Furr-Holden CDM, Ialongo NS, Anthony JC, Petras H, Kellam SG. Developmentally inspired drug
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Gunn B, Smolkowski K, Biglan A, Black C, Blair J. Fostering the development of reading skill through
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Haggerty KP, Fleming CB, Catalano RF, Harachi TW, Abbott RD. Raising healthy children: examining
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Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 44
Hawkins JD, Catalano RF, Kosterman R, Abbott RD, Hill KG. Preventing adolescent health-risk
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Ialongo NS, Werthamer L, Kellam SG, Brown CH, Wang S, Lin Y. Proximal impact of two first-grade
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Izzo C, Eckenrode J, Smith E, et al. Reducing the impact of uncontrollable stressful life events
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Kellam SG, Brown CH, Poduska JM, et al. Effects of a universal classroom behavior management
program in first and second grades on young adult behavioral, psychiatric, and social outcomes.
Drug Alcohol Depend. 2008;95(Suppl 1):S5-S28.
Kellam SG, Rebok GW, Ialongo N, Mayer LS. The course and malleability of aggressive behavior from
early first grade into middle school: results of a developmental epidemiologically-based preventive
trial. J Child Psychol Psychiatr. 1994;35(2):259-281.
Lonczak HS, Abbott RD, Hawkins JD, Kosterman R, Catalano RF. Effects of the Seattle Social
Development Project on sexual behavior, pregnancy, birth, and sexually transmitted disease
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Lunkenheimer ES, Dishion TJ, Shaw DS, et al. Collateral benefits of the Family Check-Up on early
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delinquency among low-income children: long-term intervention in elementary schools. Am J
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Olds DL, Eckenrose J, Henderson CR, Jr., et al. Long-term effects of home visitation on maternal life
course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA.
1997;278(8):637-643.
Olds DL, Henderson CR Jr., Tatelbaum R, Chamberlin R. Improving the delivery of prenatal care and
outcomes of pregnancy: a randomized trial of nurse home visitation. Pediatrics. 1986;77(1):16-28.
Olds DL, Henderson CR Jr., Tatelbaum R, Chamberlin R. Improving the life-course development of
socially disadvantaged mothers: a randomized trial of nurse home visitation. Am J Public Health.
1988;78(11):1436-1445.
Olds DL, Henderson CR, Jr., Cole R, et al. Long-term effects of nurse home visitation on children’s
criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA.
1998;280(14):1238-1244.
Olds DL, Henderson CR, Jr., Kitzman H. Does prenatal and infancy nurse home visitation have
enduring effects on qualities of parental caregiving and child health at 25 and 50 months of life?
Pediatrics. 1994;93(1):89-98.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 45
Olds DL, Kitzman H, Cole R, et al. Enduring effects of prenatal and infancy home visiting by nurses
on maternal life course and government spending: follow-up of a randomized trial among children
at age 12 years. Arch Pediatr Adolesc Med. 2010;164(5):419-424.
Olds DL, Robinson J, O’Brien R, et al. Home visiting by paraprofessionals and by nurses: a
randomized controlled trial. Pediatrics. 2002;110(3):486-496.
Olds DL, Robinson J, Pettitt L, et al. Effects of home visits by paraprofessionals and by nurses: age 4
follow-up results of a randomized trial. Pediatrics. 2004;114:1560-1568.
Olds DL. Prenatal and infancy home visiting by nurses: from randomized trials to community
replication. Prev Sci. 2002;3(3):153-172.
Petras H, Kellam SG, Brown CH, Muthen BO, Ialongo NS, Poduska JM. Developmental
epidemiological courses leading to antisocial personality disorder and violent and criminal
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to the prevention of early conduct problems: 2-year effects of the family check-up in early
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Stoolmiller M, Eddy JM, Reid JB. Detecting and describing preventive intervention effects in a
universal school-based randomized trial targeting delinquent and violent behavior. J Consult Clin
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Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 46
Tolan P, Gorman-Smith D, Henry D. Supporting families in a high-risk setting: proximal effects of the
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Tolan PH, Gorman-Smith D, Henry D, Schoeny M. The benefits of booster interventions: evidence
from a family-focused prevention program. Prev Sci. 2009;10(4): 287-297.
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Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 47
NIDA-supported research over the past 3 decades has resulted in the development of a
range of early intervention substance abuse prevention programs that span the prenatal
period, infancy and toddlerhood (0 to 3 years), preschool (3 to 6), and the transition to
elementary school (6 to 8). The programs described in this chapter are arranged by
developmental period. Within each age range, programs are presented according to level of
prevention—universal, selective, and tiered. (Not all prevention levels exist within each age
range.) Contact information is provided for each of the programs listed. Research findings
regarding the specific programs can be found following each program description. (See
“NIDA-Funded Early Interventions.”)
NIDA-Funded Early Interventions
Prenatal/Infancy and Toddlerhood
Universal Programs
Target Population
Context
Reference
Durham Connects
Mother, Father
(when possible),
Child
Family
Dodge et al., 2013a
Selective Programs
Target Population
Context
Reference
Early Steps, Family
Check Up
Mother, Child
Family
Shaw et al., 2006
Family Spirit
Mother, Child
Family
Mullany et al., 2012
Nurse Family
Partnership
Mother, Father
(if present), Child
Family
Olds, 2002b
Preschool
Selective Programs
Target Population
Context
Reference
Multidimensional
Treatment Foster
Care for Preschoolers
Foster family, Child
Family, School
Fisher &
Chamberlain, 2000
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 48
Transition to Elementary School
Universal Programs
Target Population
Context
Reference
Caring School
Community Program
School, Teacher,
Family, Child
School, Family
Battistich et al., 1997
Classroom-Centered
Intervention
Classroom, Child
School
Kellam & Rebok,
1992
Linking the Interests
of Families and
Teachers
Classroom, Child,
Family
School, Family
Reid et al. 1999
Raising Health
Children
Family, Child,
Classroom
School, Family
Catalano et al., 2003
SAFEChildren
Family, Child
School, Family
Tolan et al., 2004
Seattle Social
Development Project
School,
Parent/Family, Child
School, Family
Hawkins et al., 1999
Selective Programs
Target Population
Context
Reference
Early Risers "Skills
for Success" Risk
Prevention Program
Parent, Child
School, Family
August et al., 2001
Kids in Transition to
School
Child
School
Pears et al., 2007
Tiered Programs
Target Population
Context
Reference
Fast Track
Prevention Trial for
Conduct Problems
Family, School, Class,
Child
School, Family,
Community
Conduct Problems
Prevention Research
Group, 2000
Incredible Years
Family, Child,
Classroom
School, Family
Webster-Stratton et
al., 2008
Positive Action
Family, School, Class,
Child
School
Flay et al., 2001
Schools and Homes
in Partnership
Parent, Child
School, Family
Barrera et al., 2002
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 49
Prenatal/Infancy and Toddlerhood (Ages 0 to 3 Years)
Universal Programs
Durham Connects. Durham Connects is a brief, universal postnatal nurse home-visiting
program designed to assess family needs and connect parents with community resources
to improve infant health and well-being. Important aims are to alleviate parent substance
use and other problems and to prevent child abuse. Designed for population-level
implementation, it engages every family but rapidly triages and concentrates resources on
families with assessed higher needs. The highly structured program consists of four to
seven scripted intervention contacts, beginning with consent during a birthing hospital
visit when a staff member communicates the importance of community support for
parenting, one to three nurse home visits when the infant is between 3 and 12 weeks old,
one to two nurse contacts with a community service provider, and a telephone or home
follow-up 1 month later.
Findings: In a population-level randomized controlled trial with almost 5,000
families, families assigned to Durham Connects had 50 percent less emergency
medical care use across the first 12 months of life than the control group. This
population-level program yields similar benefits to other, more intensive nurse
visiting programs that have found reductions in service usage in infancy (Dodge et
al., 2013b).
Contact for materials and research:
Kenneth A. Dodge, Ph.D.
Duke University
Center for Child and Family Policy
Box 90545
Durham, NC 27708-0545
Phone: 919-613-9303
Fax: 919-684-3731
E-mail: dodge@duke.edu
www.childandfamilypolicy.duke.edu
Selective Programs
Early Steps, Family Check-Up (Early Steps FCU). Early Steps FCU is a brief selective
intervention designed to support families with young children (ages 2 through 5) who may
experience stress due to income or other family circumstances. It is a brief (three-session)
family intervention that consists of an initial parent interview followed by family
assessment and a feedback session; there is an option for additional follow-up sessions on
parent management support using an empirically validated curriculum (Everyday
Parenting). Early Steps FCU aims to improve parenting practices, increase the involvement
of caregivers with children, and link parents to support services with the goal of preventing
the development of childhood problem behaviors. A benefit of this intervention is that it
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 50
works with individual families to identify specific needs and strengths, thus tailoring the
intervention to each family’s needs.
Findings: To test the Early Steps FCU, participants were identified through a
national family nutrition and health program for young families referred to as the
Women, Infants, and Children Nutrition Program (WIC). Early Steps FCU resulted in
reduced problem behaviors, especially among the highest risk children. This effect
on child behavior was accounted for by improvements in positive parenting. The
Early Steps FCU was also found to be associated with attenuated internalizing
behavior, increased self-regulation, and improved language skills among children
and reduced depressive symptoms in mothers. This highlights that prevention
interventions can improve parenting practices and reduce problem behaviors in
children, and improve parental functioning (Dishion et al., 2008).
Contact for materials, research, and support for training:
Thomas Dishion, Ph.D.
Professor
Department of Psychology
Director
Prevention Research Center
Arizona State University
900 South McAllister Avenue
Tempe, AZ 85287
E-mail: dish[email protected]
Phone: 480-965-5405
Fax: 480-965-5430
Family Spirit. Family Spirit is a pregnancy and early
childhood selective prevention intervention for
American Indian teen mothers and their children,
delivered by Native paraprofessionals (local
workers trained and supervised by professionals to
deliver the program) in home visits. Sessions target
parenting skills across early childhood (0 to 3
years), maternal substance abuse prevention and
life skills, and positive child psychosocial
development. The program consists of 43 highly
structured lessons, occurring weekly through
pregnancy, biweekly in the first 3 months after
childbirth, monthly between 4 and 12 months, and
bimonthly between 12 and 36 months.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 51
Findings: Recent findings for the Family Spirit intervention showed that, at 12
months postpartum, intervention mothers had greater parenting knowledge,
parenting self-efficacy, and home safety attitudes with fewer externalizing
behaviors (opposition/defiance, rule breaking, and social problems) than the
control group. Their children also had fewer externalizing problems. In a sub-
sample of mothers with any lifetime substance use at baseline, children of substance
users in the intervention versus control group were found to have fewer
externalizing and dysregulation problems, and fewer scored in the clinically "at risk"
range for externalizing and internalizing problems (Barlow et al., 2006; Barlow et
al., 2012).
Contact for materials and research:
Allison Barlow, Ph.D.
Johns Hopkins Center for American Indian Health
621 North Washington Street
Baltimore, MD 21205
E-mail: abarlo[email protected]
Phone: 410-614-2072 or 410-294-1362
Fax: 410-955-2010
www.jhsph.edu/caih
Nurse Family Partnership. Nurse Family Partnership is a selective prenatal and infancy
home visitation program for young first-time mothers from low socio-economic
backgrounds and their children through age 2. The program’s primary goals are to improve
the outcomes of pregnancy by helping pregnant women improve their health, for instance
through diet and discontinuing cigarette, alcohol, or other drug use; to improve children’s
subsequent health and development by promoting competent parental caregiving; and to
improve parents’ economic self-sufficiency by helping them develop a vision for the future
of their families and to make appropriate decisions about completing their educations,
finding work, and planning the timing of subsequent pregnancies. The program consists of
64 structured visits beginning as early in pregnancy as possible and continuing through the
first 2 years of the child’s life. Nurses adapt the content and frequency of visits to meet
families’ needs and aspirations.
Findings: Findings on this program have confirmed that the Nurse Family
Partnership (NFP) intervention produces a broad array of positive effects on
immediate and intermediate outcomes, including improved maternal, infant, and
child health and reduced injuries, neglect, and maltreatment of children. There are
also long-term effects on child outcomes. For example, children in the NFP
intervention group had lower rates of substance use, delinquency, and involvement
in the juvenile justice system at age 12 than control group children. This
intervention is effective with diverse populations (e.g., rural and urban) but not as
effective when implemented by trained paraprofessionals; hence, nurse
participation is a key aspect of this intervention (Kitzman et al., 2010; Olds et al.,
2010).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 52
Contact for information on implementation:
Nurse-Family Partnership National Service Office
1900 Grant Street
Suite 400
Denver, CO 80203
E-mail: info@nursefamilypartnership.org
Phone: 866-864-5226
Fax: 303-327-4260
www.nursefamilypartnership.org
Contact for materials and research:
David L. Olds, Ph.D.
Prevention Research Center for Family and Child Health
University of Colorado Health Sciences Center
1825 Marion Street
Denver, CO 80220
E-mail: dav[email protected]u
Phone: 303-724-2892
Preschool (Ages 3 to 6 Years)
Selective Programs
Multidimensional Treatment Foster Care for Preschoolers (MTFC-P) (Formerly Early
Intervention Foster Care [EIFC]). MTFC-P is a selective intervention for 3- to 6-year-old
children in foster care. It attempts to create optimal foster care conditions (including
providing responsive and consistent caregiving and predictable daily routines) to facilitate
developmental progress and address difficulties related to delayed maturation and
behavioral and emotional problems. Children are referred from the child welfare system by
their caseworkers. The intervention is delivered by family therapists and licensed
psychologists who provide parenting training and access to resources for foster parents
above and beyond those offered in regular foster care. Prior to bringing a new foster child
into their home, foster parents receive 12 hours of training during which they learn how to
concretely encourage pro-social behavior, consistently and non-abusively set limits to
address disruptive behavior, and give children close supervision. Foster parents attend
weekly support group meetings and have frequent telephone contact with intervention
staff, including access to a 24-hour crisis hotline. The children receive weekly
individualized skills training services from a child therapist and attend a weekly
therapeutic playgroup. In addition, family therapists work with families to facilitate the
transition out of foster care and into a permanent home.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 53
Findings: Children in this early intervention foster care program showed more
secure behaviors, improved response to feedback, and improved sleep. They also
showed reduced stress, measured by the level of the hormone cortisol. Over the
course of MTFC-P placement, children’s cortisol levels normalized and became
similar to those of a control group of non-maltreated children living with their
biological parents. Another measure of child function among children in foster care
is disrupted placement, with children who function better staying in a placement
rather than being moved to another foster home. Successful transitions into
permanent homes were significantly higher for children in the early intervention
foster care program compared to children in regular foster care (Fisher et al., 2007;
Fisher et al., 2009).
Contact for materials and research:
Philip A. Fisher, Ph.D.
Oregon Social Learning Center
10 Shelton McMurphey Boulevard
Eugene, OR 97401
E-mail: [email protected]
Phone: 541-485-2711
Fax: 541-485-7087
www.oslc.org, www.oslccp.org
Transition to School (Ages 6 to 8 Years)
Universal Programs
Caring School Community Program (Formerly Child
Development Project). This is a universal family
and school intervention to reduce risk factors and
bolster protective factors among children making
the transition to elementary school. The program
focuses on strengthening students’ “sense of
community,” or connection to school, which
research has shown to be pivotal in reducing drug
use, violence, and mental health problems and
promoting academic motivation and achievement.
The program consists of a set of classroom, school,
and family involvement approaches that reinforce
the development of skills by children across
contexts. These promote positive peer, teacher-student, and home-school relationships and
the development of social, emotional, and character-related skills. The program provides
detailed instructional, implementation, and staff development materials.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 54
Findings: Research results showed a significant reduction in students’ drug use and
involvement in other problem behaviors in schools where the Caring School
Community Program was widely implemented by teachers over a period of 3 years,
compared to schools not implementing the program (Battistich et al., 2000).
Contact for Materials and Research:
Peter Brunn
Caring School Community Program
Developmental Studies Center
2000 Embarcadero
Suite 305
Oakland, CA 94606
E-mail: Peter_Brunn@devstu.org
Phone: 510-533-0213
Fax: 510-464-3670
www.devstu.org
Classroom-Centered (CC) Intervention.
The CC Intervention is a multi-component, universal
first-grade preventive intervention targeting early aggressive or disruptive behavior and
poor academic achievement, with the long-term goal of reducing adolescent and adult
antisocial behavior and substance abuse. The CC Intervention enhances teachers' behavior
management and instructional skills through the use of an effective classroom behavior
management program called the “Good Behavior Game” and an enhanced reading and
mathematics curricula.
Findings: Results from an ongoing follow-up study indicate that the CC Intervention
decreased the level of conduct problems in middle and high school, delayed the
onset of smoking tobacco in both males and females, and was associated with an
increased likelihood of high school graduation and a lower likelihood of special
education use. While broad benefits of this intervention have been found, the effects
of the CC Intervention are strongest for males who exhibit a relatively high level of
aggressive-disruptive behavior in the early elementary school years, indicating that
this universal intervention can have a targeted impact on a high-risk group of
children. In a study of the Good Behavior Game, males in the intervention group who
were more aggressive in 1
st
grade had higher rates of high school graduation, lower
rates of alcohol and drug abuse and dependence, and lower rates of antisocial
personality disorder at ages 19 to 21 than males in the control condition (Bradshaw
et al., 2009; Wang et al., 2012).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 55
Contact for materials and research:
Nicholas Ialongo, Ph.D.
Department of Mental Health
Johns Hopkins Bloomberg School of Public Health
Johns Hopkins University
624 North Broadway
Baltimore, MD 21205
E-mail: nialong[email protected]
Phone: 410-955-0414
Fax: 410-955-9088
www.jhsph.edu/prevention
Linking the Interests of Families and Teachers (LIFT). LIFT is a universal preventive
intervention that was developed for elementary schools in communities with high levels of
juvenile delinquency. Created for students in the 1
st
and 5
th
grades, LIFT is a multi-
component intervention that is designed to improve school and family environments while
also reinforcing stronger links between the two. Two school components are designed to
decrease the likelihood of both aggressive child behavior and rejection of aggressive
children by their peers: A classroom component improves upon social and problem solving
skills during 20 1-hour-long sessions, and a playground component based on the Good
Behavior Game (see the CC Intervention) reinforces positive social behaviors during free
(unstructured) play. There is also a parent management training component emphasizing
good discipline, supervision, and problem-solving during a group meeting, once a week for
6 weeks, as well as parent support between sessions. In addition, a school-parent
communication component supports connections between the families and teachers
through phone, email, and Internet, as well as a weekly newsletter sent to parents
describing the LIFT activities of the week and suggesting complementary home activities.
Findings: Within the context of a randomized controlled trial of 12 schools, LIFT
resulted in improvements in parenting behaviors and child social skills as well as
reduced child physical aggression on the playground. During their middle and high
school years, children in schools assigned to the LIFT intervention had lower rates
of police arrest and substance use compared to children in control schools
(DeGarmo et al., 2009; Eddy et al., 2000).
Contact for materials and research:
J. Mark Eddy, Ph.D.
Partners for Our Children
School of Social Work
University of Washington
UW Mailbox 359476
Seattle, WA 98195
E-mail: jmark[email protected]
Phone: 206-221-3144
Fax: 206-221-3155
www.partnersforourchildren.org
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 56
Raising Healthy Children (RHC). RHC is a school- and home-based intervention targeting
children in grades 1 through 12. It engages classroom teachers, parents, and students with
the goal of increasing pro-social behavior and reducing substance use and other problem
behavior by addressing developmentally salient risk and protective factors. Teachers
attend workshops to improve instruction and classroom management practices and have
access to one-on-one classroom-based coaching to help them implement the techniques
they have learned. Parents participate in parenting workshops and brief, individual, in-
home sessions as students approach critical transitions in adolescence. Children learn
social, emotional, and cognitive skills through classroom, after-school, and parent-youth
sessions. In addition, families have access to school-home coordinators (SHCs) who check
in with families several times a year and help solve problems that arise.
Findings: Students who participated in
the RHC intervention showed higher
academic performance, a stronger
commitment to school, and increased
social competency. They also showed
lower levels of antisocial behavior and
less frequent alcohol and marijuana use,
and were less likely to drive under the
influence of alcohol or ride with
someone who had been drinking alcohol.
Reductions in driving under the
influence and riding with another driver
under the influence were sustained
through age 20. As such, the RHC
intervention has been shown to promote healthy behaviors and academic
achievement, reduce substance use and antisocial behaviors, and reduce drunk
driving (Brown et al., 2005; Haggerty et al., 2006).
Contact for materials and research:
Kevin Haggerty, Ph.D.
Associate Director, Social Development Research Group
University of Washington School of Social Work
9725 3rd Avenue NE
Suite 401
Seattle, WA 98115
E-mail: hagg[email protected]n.edu
Phone: 206-543-3188
Fax: 206-543-4507
www.sdrg.org
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 57
SAFEChildren. SAFEChildren is a universal intervention with school and family components
developed specifically for 1
st
graders from urban, disadvantaged, or low-income
neighborhoods. This program is designed to help families protect their children from the
risks of growing up in communities with high levels of poverty and crime and few social
and economic resources. SAFEChildren also specifically focuses on helping inner-city
parents manage a child’s transition to school with the goal of promoting academic
achievement and overall child well-being. The family component brings multiple families
together in a group setting once a week for 22 weeks. During these meetings, families
receive information about parenting skills, family relationships, and understanding and
managing developmental and situational challenges. In addition, there are opportunities to
practice skills and solve problems as a group. These multiple-family groups increase
support among parents and help families become more engaged with the school and more
engaged in managing issues such as problems in the neighborhood. The school component
consists of a tutoring program that takes place twice weekly for 22 weeks and emphasizes
phonetics as well as a step-by-step advancement in academic skills.
Findings: The SAFEChildren intervention has been shown to improve reading level
overall. Among higher-risk families, characterized by poorer family relationships
and parenting practices, the SAFEChildren intervention led to improved parental
monitoring and reduced child aggression. Furthermore, higher-risk children,
characterized by greater aggression and hyperactivity as well as poorer
concentration, showed greater reduction in aggression and hyperactivity as well as
improved leadership skills. Also, SAFEChildren had an effect on ADHD symptoms
from first grade to fourth grade, with intervention children less likely to be rated as
high on impulsivity and hyperactivity, over this time frame (Fowler et al., 2014).An
additional version of SAFEChildren was developed for 4
th
grade to deliver booster
sessions. Those assigned to the booster showed lower rates of aggression than those
with only 1
st
-grade intervention (Tolan et al., 2009).
Contact for materials and research:
Patrick Tolan, Ph.D.
Youth-Nex: The UVA Center to Promote Effective Youth Development
University of Virginia
400 Emmet Street South
PO Box 400281
Charlottesville, VA 22904
E-mail: pht6t@virginia.edu
Phone: 434-243-9551
Fax: 434-982-6035
www.curry.virginia.edu/youth-nex
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 58
Seattle Social Development Project (SSDP). SSDP is a universal intervention for elementary
school children with a school component and voluntary family component, developed to
increase pro-social bonds, strengthen attachments to school, and decrease delinquency.
The family component consists of parenting classes that cover family management (1
st
and
2
nd
grade), engagement in a child’s education (2
nd
and 3
rd
grade), and the drug abuse
prevention program Preparing for the Drug Free Years (PDFY) (5
th
and 6
th
grade). In the
school component, teachers are trained to establish clear rules and reward compliance,
teach interactively, and promote cooperative learning in small groups. The goal is to
increase the students’ academic performance as well as social skills and increase contact
with pro-social peers. In addition, children are taught interpersonal problem-solving skills
to improve communication, decision-making, negotiation, and conflict resolution. SSDP is
the original intervention that serves as the basis for the Raising Healthy Children (RHC)
intervention.
Findings: The SSDP intervention was associated with reduced aggressive behavior
in males and reduced self-destructive behavior in females. It has also been shown to
reduce delinquency and alcohol use for both males and females. Females were also
less likely to have smoked cigarettes and somewhat less likely to have tried
marijuana. Further, there is evidence that SSDP increases attachment to school,
cooperative learning, and academic achievement. Intervention effects were
strongest among children from lower income households. Long-term effects of the
SSDP intervention found that those children who received the intervention had less
risky sexual behavior (fewer partners, sexually transmitted infections, and
pregnancies, and more condom use), were more likely to graduate high school, were
more likely to become gainfully employed, and have less involvement with the
criminal justice system (Hawkins et al., 2008).
Contact for materials and research:
Karl G. Hill, Ph.D.
Social Development Research Group
School of Social Work
University of Washington
9725 3rd Avenue NE
Suite 401
Seattle, WA 98115
E-mail: khill@uw.edu
Phone: 206-685-3859
Fax: 206-543-4507
www.ssdp-tip.org/SSDP/index.html
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 59
Selective Programs
Early Risers “Skills for Success” Risk Prevention Program. Early Risers is an intervention for
children at higher risk for the development of serious conduct problems, including the use
and misuse of drugs. Elementary school-aged children ages 6 to 10 are selected for the
program based on the presence of risk factors including exposure to stressful life
experiences and/or early aggressive and disruptive behavior. The program is designed to
deflect children from the “early starter” developmental pathway toward normal
development by improving their academic competence and behavioral self-regulation and
encouraging positive peer affiliations. The program also teaches parenting practices that
include discipline, nurturance, and involvement. The Early Risers intervention model
includes two child-focused components and two parent- or family-focused components
delivered over a 2- to 3-year period. The program includes standard skills curricula as well
as strategies tailored to address the individual needs and goals of children and their
parents.
Findings: In efficacy and effectiveness trials
of Early Risers, program participants have
demonstrated greater gains in social skills,
peer reputation, pro-social friendship
selection, academic achievement, and
parent discipline than did controls. The
program has been replicated with African-
American children. Findings from a 6-year
follow-up indicated that the gains in social
skills and parent discipline observed early
on accounted, in part, for fewer oppositional
defiant disorder symptoms among program
participants compared with controls in middle school. Recently, in a going-to-scale
trial, Early Risers was implemented with high fidelity across 28 school sites, and
children made positive gains on outcomes similar to those found in the efficacy trial
(August et al., 2003).
Contact for materials and research:
Gerald J. August, Ph.D.
Division of Child and Adolescent Psychiatry
University of Minnesota Medical School
P256/2B West
2450 Riverside Avenue
Minneapolis, MN 55454
E-mail: [email protected].edu
Phone: 612-273-9711
Fax: 612-273-9779
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 60
Kids in Transition to School (KITS). KITS is a selective prevention intervention designed to
enhance psychosocial and academic readiness in children in the foster care system as they
enter school by promoting pre-literacy skills and increasing their attention, effortful
control, and social skills in classroom settings. The program gives caregivers skills for
facilitating their children's successful transition to kindergarten and becoming involved in
their children’s schooling. The KITS intervention targets specific school-related skills
during the summer before and the first weeks of kindergarten via a therapeutic playgroup;
caregiver psycho-educational support groups; and behavioral consultation in the home,
school, and community settings.
Findings: Recent findings from a randomized controlled trial of KITS showed
positive effects on outcomes in childhood that are linked to later risk for drug use.
Children who received the KITS intervention had lower levels of oppositional and
aggressive behaviors in the classroom. Also, there were positive intervention effects
on early literacy and self-regulatory skills (Pears et al., 2013; Pears et al., 2012).
Contact for materials and research:
Katherine Pears, Ph.D.
Oregon Social Learning Center
10 Shelton McMurphey Boulevard
Eugene, OR 97401
E-mail: kather[email protected]g
Phone: 541-485-2711
Fax: 541-485-7087
www.oslc.org
Tiered Programs
Fast Track Prevention Trial for Conduct Problems. Fast Track is a tiered comprehensive
preventive intervention delivered in grades 1 through 10 to children at high risk for long-
term antisocial behavior. Based on a developmental model, the intervention includes a
universal classroom program (adapted from the Promoting Alternative Thinking Strategies
[PATHS] curriculum) delivered in elementary school. This classroom intervention builds
skills in emotional understanding and communication, friendship, self-control, and social
problem-solving. In addition, the program includes selective interventions for high-risk
children displaying elevated aggression at home and school, as assessed in kindergarten.
These high-risk children receive social skills training and academic tutoring, and their
parents receive group parent training and individual home visits. Child-focused skill
training targets academic and social competencies as well as self-control skills. Parent
training builds parents’ self-control and targets skills to support the child’s school
adjustment, improve the child’s behavior, promote appropriate expectations for the child’s
behavior, and improve parent-child interaction.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 61
Findings: By the end of 12
th
grade, the Fast Track intervention was found to reduce
adolescent delinquency as indicated by youth self-reports and official arrest records
and, for the youths at highest risk, to reduce lifetime prevalence for conduct
disorder, oppositional defiant disorder, attention deficit hyperactivity disorder, and
any externalizing disorder. At the end of elementary school, children in Fast Track
were found to have significantly reduced home and community problems, which
included past-year involvement in substance use behaviors. There was no
significant effect of the intervention on the onset of delinquent acts that included
selling controlled substances. By the end of 12
th
grade, children in Fast Track had
significantly fewer visits to general health providers, pediatric providers, and
emergency departments for emotional, behavioral, academic, drug, or alcohol
problems. At age 25 years, assignment to intervention significantly decreased the
probability of alcohol abuse, marginally decreased binge drinking, did not affect
heavy marijuana use, and significantly decreased serious substance use (Conduct
Problems Prevention Research Group, 2011; Conduct Problems Prevention
Research Group, 2015).
Contact for materials and research for Fast Track:
Fast Track & Fast Track Data Center
Bay C, 2nd Floor, Mill Building
2024 West Main Street
Duke Box 90539
Durham, NC 27708
E-mail: www.fasttrackproject.org/contact.php
Phone: 814-865-3879
Fax: 814-865-3246
www.fasttrackproject.org
Contact for materials for PATHS:
Channing Bete Company
One Community Place
South Deerfield, MA 01373
E-mail: PrevSci@channing-bete.com
Phone: 877-896-8532
Fax: 800-499-6464
www.channing-bete.com
Contact for research for PATHS:
Mark T. Greenberg, Ph.D.
Prevention Research Center
Pennsylvania State University
110 Henderson Building South
University Park, PA 16802
E-mail: mxg47@psu.edu
Phone: 814-863-0112
Fax: 814-865-2530
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 62
www.episcenter.psu.edu/ebp/altthinking
Contact for training for PATHS:
Carol A. Kusché, Ph.D.
PATHS Training, LLC
927 10th Avenue East
Seattle, WA 98102
E-mail: ckusche@comcast.net
Phone and Fax: 206-323-6688
www.pathstraining.com
Incredible Years
Parents, Teachers, and Children’s Training Series. The Incredible Years
series is a tiered, multi-component prevention and treatment intervention implemented in
day care, preschool (2 to 5 years), and early primary grades (6 to 8 years). The prevention
version of the program can be offered in high-risk schools or day care centers to all parents,
teachers, and children; or parents and teachers may identify children at moderate or higher
risk based on elevated behavior problem ratings. The treatment version is used for
children identified as having behavioral or conduct problems. The comprehensive
intervention consists of a parent training component as well as school-based teacher
training and child training components.
The Incredible Years parenting program
instructs parents in child-directed play, academic
and persistence coaching, social and emotional
coaching, use of praise and tangible incentives, and
positive discipline methods that promote positive
relationships and strengthen children’s language
development, social and emotional competence,
school readiness skills, problem-solving, and anger
management. Different parent curricula are
available for different child developmental stages
and teach parents how to partner with day care
providers and teachers to develop individualized
behavior plans. The program consists of weekly, 2-
hour parent group meetings with a group leader and/or counselor for a total of 14 to 18
sessions or more. The number of sessions varies according to the child’s age, the parent’s
needs, and whether the prevention or treatment version of the program is being used.
The Incredible Years child program, also called the Dina Dinosaur Social Skills Program
for young children (Dinosaur School), teaches children school rules, strategies for success
in school, feelings literacy, empathy training and emotional regulation, problem-solving
skills, and friendship skills. The prevention version of this program can be delivered by
classroom teachers throughout the school year two to three times per week, with
structured circle time lesson plans and hands-on small group activities. The program uses
developmentally appropriate lesson plans for children in preschool through 2
nd
grade (3 to
8 years old).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 63
The Incredible Years teacher classroom management program trains teachers in
effective classroom management strategies as well as ways to collaborate with parents to
promote consistency of learning from school to home. This program can be delivered to all
teachers in a school or to selected teachers who have particularly challenging children in
their classrooms. The training is group-based and delivered in six day-long sessions once a
month throughout the year, accompanied by individual coaching within the schools.
Findings: Each of the Incredible Years programs has been researched in their
prevention and treatment versions. Parent programs consistently result in higher
rates of positive parenting behaviors and fewer child behavior problems at home.
The child program results in improved social interactions and problem-solving with
peers, increased in-school readiness behaviors, and decreased aggression and
negative behavior with peers. The teacher program results in increased use of
positive classroom management strategies, less negative or critical teaching, more
focus on providing children with social emotional curriculum, and increased home-
school collaboration (Webster-Stratton & Reid, 2010; Webster-Stratton et al., 2004).
Contact for materials and research:
Lisa St. George
Administrator Director
Incredible Years
1411 8th Avenue West
Seattle, WA 98119
E-mail: lisastgeorge@comcast.net
Phone and fax: 206-285-7565
www.incredibleyears.com
Positive Action (PA). The PA intervention is a tiered, multi-component, school-based, social-
emotional and character development program designed to improve academics and pro-
social behaviors as well as decrease problem behaviors. Components of this intervention
target the classroom and the overall school climate as well as families and the community.
The classroom component consists of grade-specific curricula, which can be implemented
beginning as early as Pre-K and extending through grade 12. The lessons cover six broad
categories: self-concept, physical and intellectual actions, social/emotional actions for
managing oneself responsibly, getting along with others, being honest with oneself and
others, and continuous self-improvement. The overall school climate supports the
classroom curriculum through ongoing reinforcement of positive behaviors, posters,
assemblies, newsletters, and other means. In addition, school counselors work with
selected higher-risk students and families to develop PA skills. The family component
provides caregivers with resources that parallel the classroom curricula to further
reinforce the messages children are receiving at school. The PA intervention also helps
establish media messages and civic engagement activities for the larger community in
which the children live.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 64
Findings: Children who participated in the PA program had improved academic
achievement and lower rates of substance use, violence, sexual activity, and
absenteeism. Furthermore, the effects of PA on child outcomes increase with
multiple years of exposure to the program (Beets et al., 2009; Flay & Allred, 2010;
Snyder et al., 2010).
Contact for materials and research:
Positive Action, Inc.
264 4th Avenue South
Twin Falls, ID 83301
E-mail: info@positiveaction.net
Phone: 800-345-2974
Fax: 208-733-1590
www.positiveaction.net
School and Homes in Partnership (SHIP). The SHIP intervention is a tiered intervention for
children in kindergarten through 3
rd
grade who have aggressive behavior problems or
reading difficulties. It is implemented over the course of 2 academic years and includes
parent training, a social behavior intervention, and reading instruction. The parent training
component is administered in either Spanish or English and consists of the Incredible Years
parenting program delivered over 12 to 16 sessions. There are two components to the
social behavior intervention. The first component, Contingencies for Learning Academic
and Social Skills (CLASS), involves the child working directly with a trained consultant,
then the teacher, and lastly the teacher and parents to reduce acting out and improve
appropriate classroom behavior. The second component is the Dina Dinosaur Social Skills
Program (see Incredible Years), a 2-hour after-school program using puppets and video
tapes to model appropriate behavior to children. The reading instruction component
consists of daily small-group instruction in phonemic awareness, sound-letter
correspondence, and blending. Additional instruction is provided for those students who
are still non-readers in the 3
rd
and 4
th
grades.
Findings: SHIP has been evaluated among both European-American and Hispanic
children. It was found to reduce aggressive or anti-social behavior, particularly for
those children with early aggressive behavior problems. SHIP has also been found to
improve reading abilities (Gunn et al., 2005; Smolkowski et al., 2005).
Contact for materials and research:
Anthony Biglan
Oregon Research Institute
1776 Millrace Drive
Eugene, OR 97403
E-mail: tony@ori.org
Phone: 541-484-2123
Fax: 541-484-1108
www.ori.org
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 65
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Flay BR, Allred CG, Ordway N. Effects of the Positive Action program on achievement and discipline:
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Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 69
Below are resources relevant to drug abuse prevention. Information on NIDA’s website is
followed by websites for other federal agencies and other public and private organizations.
These resources are excellent sources of information on research-based early childhood
drug prevention programs.
National Institute on Drug Abuse (NIDA)
National Institutes of Health (NIH)
U.S. Department of Health and Human Services (HHS)
NIDA’s website (www.drugabuse.gov) provides factual information on all aspects of drug
abuse, particularly the effects of drugs on the brain and body, the prevention of drug abuse
among children and adolescents, the latest research on treatment for addiction, and
statistics on the extent of drug abuse in the United States. The website allows visitors to
access publications, public service announcements and posters, science education
curricula, research reports and fact sheets on specific drugs or classes of drugs, and the
NIDA NOTES newsletter. The site also links to related websites in the public and private
sectors.
The Prevention Research Branch (PRB) of NIDA’s Division of Epidemiology, Services and
Prevention Research (DESPR) website is a great resource for more information on the
latest research on the prevention of drug abuse.
Other Federal Resources
U.S. Department of Education (ED)
400 Maryland Avenue, SW
Washington, DC 20202
Phone: 800-872-5327
www.ed.gov
Office of Safe and Healthy Students (in the Office of Elementary and Secondary
Education (OESE)) http://www2.ed.gov/about/offices/list/oese/oshs/index.html
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 70
U.S. Department of Health and Human Services (HHS)
200 Independence Avenue, SW
Washington, DC 20201
Phone: 877-696-6775
www.hhs.gov
Administration for Children and Families (ACF)
370 L’Enfant Promenade, SW
Washington, DC 20447
Phone: 202-401-9200
www.acf.hhs.gov
Children’s Bureau www.acf.hhs.gov/programs/cb
Office of Child Care (OCC) www.acf.hhs.gov/programs/occ
Office of Head Start (OHS) www.acf.hhs.gov/programs/ohs
Office of Planning, Research and Evaluation (OPRE)
www.acf.hhs.gov/programs/opre
Administration for Community Living (ACL)
One Massachusetts Avenue, NW
Washington, DC 20001
Phone: 202-401-4634
Administration on Intellectual and Developmental Disabilities (AIDD)
www.acl.gov/programs/aidd/index.aspx
Centers for Disease Control and Prevention (CDC)
1600 Clifton Road
Atlanta, GA 30329
Phone: 800-CDC-INFO (800-232-4636)
www.cdc.gov
National Center for Chronic Disease Prevention and Health Promotion
(NCCDPHP) www.cdc.gov/chronicdisease/index.htm
Division of Violence Prevention (DVP) www.cdc.gov/violenceprevention/
Child Maltreatment
www.cdc.gov/ViolencePrevention/childmaltreatment/index.html
National Center on Birth Defects and Developmental Disabilities (NCBDDD)
www.cdc.gov/ncbddd/index.html
Child Development
www.cdc.gov/ncbddd/childdevelopment/index.html
Legacy for Children
TM
www.cdc.gov/ncbddd/childdevelopment/legacy.html
Learn the Signs. Act Early. www.cdc.gov/ncbddd/actearly/
Parent Information www.cdc.gov/parents/index.html
National Center for Injury Prevention and Control (NCIPC)
www.cdc.gov/injury
Protect the Ones you Love: Child Injuries are Preventable
www.cdc.gov/safechild/
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 71
Health Resources and Services Administration (HRSA)
5600 Fishers Lane
Rockville, MD 20857
Phone: 888-ASK-HRSA (888-275-4772)
www.hrsa.gov
Maternal and Child Health Bureau (MCHB) www.mchb.hrsa.gov
Indian Health Service (IHS)
The Reyes Building
801 Thompson Avenue
Rockville, MD 20852
Phone: 301-443-3593
www.ihs.gov
National Institutes of Health (NIH)
9000 Rockville Pike
Bethesda, MD 20892
Phone: 301-496-4000
www.nih.gov
The Eunice Kennedy Shriver National Institute of Child Health and
Human Development (NICHD)
Bldg 31, Room 2A32, MSC 2425
31 Center Drive
Bethesda, MD 20892-2425
Phone: 800-370-2943
www.nichd.nih.gov
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
5635 Fishers Lane, MSC 9304
Bethesda, MD 20892-9304
Phone: 301-443-3860
www.niaaa.nih.gov
National Institute of Environmental Health Sciences (NIEHS)
111 T.W. Alexander Drive
Research Triangle Park, NC 27709
Phone: 919-541-3345
www.niehs.nih.gov
Children’s Health
www.niehs.nih.gov/health/topics/population/children/index.cfm
Environmental Health Topics
www.niehs.nih.gov/health/topics/index.cfm
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 72
National Institute of Mental Health (NIMH)
6001 Executive Boulevard, Room 6200, MSC 9663
Bethesda, MD 20892-9663
Phone: 866-615-6464
www.nimh.nih.gov
National Library of Medicine (NLM)
8600 Rockville Pike
Bethesda, MD 20894
Phone: 888-FIND-NLM (888-346-3656)
www.nlm.nih.gov
Office of the Assistant Secretary for Planning and Evaluation (ASPE)
200 Independence Avenue, SW
Washington, DC 20201
Phone: 877-696-6775
www.aspe.hhs.gov
Early Childhood and School Readiness
http://aspe.hhs.gov/office_specific/topic3.cfm?tpcid=51&topic=Early%20Childhoo
d%20and%20School%20Readiness&office=HSP&CFID=379200&CFTOKEN=80912
328
Substance Abuse and Mental Health Services Administration (SAMHSA)
1 Choke Cherry Road
Rockville, Maryland 20857
Phone: 877-SAMHSA-7 (877-726-4727)
www.samhsa.gov
Center for Substance Abuse Prevention (CSAP) www.samhsa.gov/prevention
U.S. Department of Agriculture
1400 Independence Avenue, SW
Washington, DC 20250
Phone: 202-720-2791
www.usda.gov
National Institute of Food and Agriculture (NIFA) www.csrees.usda.gov
Office of National Drug Control Policy (ONDCP)
P.O. Box 6000
Rockville, MD 20849
Phone: 800-666-3332
www.whitehouse.gov/ondcp
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 73
Other Selected Resources
Academic Professional Organizations
American Academy of Child and Adolescent Psychiatry (AACAP)
3615 Wisconsin Avenue, NW
Washington, DC 20016
Phone: 202-966-7300
www.aacap.org
American Academy of Family Physicians (AAFP)
11400 Tomahawk Creek Parkway
Leawood, KS 66211
Phone: 913-906-6000
www.aafp.org
www.familydoctor.org
American Academy of Pediatrics (AAP)
141 Northwest Point Boulevard
Elk Grove Village, IL 60007
Phone: 800-433-9016
www.aap.org
American Psychological Association (APA)
750 First Street, NE
Washington, DC 20002
Phone: 800-374-2121
www.apa.org
American Society of Addiction Medicine (ASAM)
4601 North Park Avenue
Upper Arcade, Suite 101
Chevy Chase, MD 20815
Phone: 301-656-3920
www.asam.org
International Society on Infant Studies (ISIS)
350 Main Street
Malden, MA 02148
Phone: 800-835-6770
www.isisweb.org
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 74
National Association for the Education Young Children (NAEYC)
1313 L Street, NW
Suite 500
Washington, DC 20005
Phone: 800-424-2460
www.naeyc.org
National Association of Pediatric Nurse Practitioners (NAPNAP)
5 Hanover Square
Suite 1401
New York, NY 10004
Phone: 917-746-8300
www.napnap.org
National Association of School Nurses
1100 Wayne Avenue
Suite 925
Silver Spring, MD 20910
Phone: 240-821-1130
www.nasn.org
National Council on Family Relations (NCFR)
1201 West River Parkway
Suite 200
Minneapolis, MN 55454
Phone: 888-781-9331
www.ncfr.org
National Hispanic Science Network (NHSN)
Health Sciences Center, New Orleans
Louisiana State University
1901 Perdido Street
New Orleans, LA 70112
Phone: 504-568-6187
http://nhsn.med.miami.edu
Society of Pediatric Nurses (SPN)
330 North Wabash Avenue
Suite 2000
Chicago, IL 60611
Phone: 312-321-5154
www.pedsnurses.org
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 75
Society for Prevention Research (SPR)
11240 Waples Mill Road
Suite 200
Fairfax, VA 22030
Phone: 703-934-4850
www.preventionresearch.org
Society for Research in Child Development (SRCD)
2950 South State Street
Suite 401
Ann Arbor, MI 48104
Phone: 734-926-0600
www.srcd.org
Other Non-Governmental Resources
Annie E. Casey Foundation
701 St. Paul Street
Baltimore, MD 21202
Phone: 410-547-6600
www.aecf.org
Center for the Study and Prevention of Violence (CSPV)
Institute of Behavioral Science
University of Colorado Boulder
483 UCB
Boulder, CO 80309-0483
Phone: 303-492-1032
www.colorado.edu/cspv/blueprints/
Casey Family Programs
2001 Eighth Avenue
Suite 2700
Seattle, WA 98121
Phone: 206-282-7300
www.casey.org
Collaborative for Academic, Social, and Emotional Learning (CASEL)
815 West Van Buren Street
Suite 210
Chicago, IL 60607
Phone: 312-226-3770
www.casel.org
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 76
CASAColumbia
633 Third Avenue, 19th Floor
New York, NY 10017
Phone: 212-841-5200
www.casacolumbia.org
Children’s Defense Fund
25 E Street, NW
Washington, DC 20001
Phone: 800-CDF-1200 (800-233-1200)
www.childrensdefense.org
Community Anti-Drug Coalitions of America (CADCA)
625 Slaters Lane
Suite 300
Alexandria, VA 22314
Phone: 800-54-CADCA (800-542-2322)
www.cadca.org
Drug Strategies, Inc.
1150 Connecticut Avenue, NW, Suite 800
Washington, DC 20036
Phone: 202-289-9070
www.drugstrategies.org
Foundation for Child Development
295 Madison Avenue
40th Floor
New York, NY 10017
Phone: 212-867-5777
www.fcd-us.org
Mentor Foundation USA
2900 K Street NW, South Building
Washington, DC 20007
Phone: 202-536-1594
www.mentorfoundation.org/usa
National Asian Pacific American Families Against Substance Abuse (NAPAFASA)
340 East 2nd Street
Suite 409
Los Angeles, CA 90012
Phone: 213-625-5795
www.napafasa.org
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 77
National Black Child Development Institute (NBCDI)
1313 L Street, NW
Suite 110
Washington, DC 20005
Phone: 800-556-2234
202-833-2220
www.nbcdi.org
National Head Start Association (NHSA)
1651 Prince Street
Alexandria, VA 22314
Phone: 866-677-8724
703-739-0875
www.nhsa.org
Partnership for Drug-Free Kids
352 Park Avenue South
9th Floor
New York, NY 10010
Phone: 212-922-1560
www.drugfree.org
Robert Wood Johnson Foundation
Route 1 and College Road East
P.O. Box 2316
Princeton, NJ 08543
Phone: 877-843-7953
www.rwjf.org
Frank Porter Graham Child Development Institute
University of North Carolina at Chapel Hill
CB 8180
Chapel Hill, NC 27599
Phone: 919-966-2622
www.fpg.unc.edu
WilliamT. Grant Foundation
570 Lexington Avenue
18th Floor
New York, NY 10022
Phone: 212-752-0071
www.wtgrantfoundation.org
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 78
Zero to Three: National Center for Infants, Toddlers, and Families
1255 23rd Street, NW
Suite 350
Washington, DC 20037
Phone: 202-638-1144
www.zerotothree.org
Other Resources
National Prevention Network (NPN)
National Association of State Alcohol/Drug Abuse Directors (NASADAD)
1025 Connecticut Avenue, NW
Suite 605
Washington, DC 20036
Phone: 202-293-0090
www.nasadad.org/national-prevention-network
United Nations Office on Drugs and Crime (UNODC)
Vienna International Centre
Wagramer Strasse 5
A 1400 Vienna
Austria
Phone: +(43) (1) 26060
http://www.unodc.org/
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 79
Through theory, observation, and behavioral study, scientists have determined that select
facets of human behavior can be changed over time. Specifically, the effects of malleable
risk factors can be reduced, protective factors can be enhanced or developed, and
resources can be accessed. An important avenue for accomplishing this is through
prevention interventions that develop knowledge, skills, and competencies in the targeted
individual(s). This provides the basic rationale for the conception and design of prevention
intervention programs.
Design of science-based interventions begins at the theoretical level, with:
• Developmental theories that explain human growth and maturation; the normal
course of physical, psychological, emotional, and cognitive changes; and what
motivates humans to behave in particular ways
• Ecological theories that specify the contexts within which individuals develop and
function and strive to explain the factors within contexts that influence changes in
behavior
• Cognitive theories that focus on internal states such as motivation, problem-solving,
decision-making, and attention
• Behavior analytic theories that focus on how behaviors and habits are acquired and
can be changed
These theories help researchers think about how patterns of behaviors develop, what
motivates individuals to behave in specific ways, and what risk and protective factors
should be examined. The influence of theory can be traced throughout the processes of
conceptualizing, developing, and testing an intervention. Theory informs thinking about
what internal and contextual factors and processes may be modifiable; this information is
then used in the development of the logic model.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 80
Logic models graphically explain how changes in malleable risk and protective factors and
behaviors will take place over time to produce positive outcomes. From the logic model
described in “Intervening in Early Childhood” (see “Logic Model for Intervening in Early
Childhood to Prevent Drug Abuse”), an intervention is developed, including the
specification of knowledge and activities designed to strengthen the resources and
capacities identified as crucial to providing protection against and reducing risk factors and
associated problem behaviors.
Intervention Timing, Context, and Components
As discussed in “Why is Early Childhood Important to Substance Abuse Prevention?,” life
course transitions in childhood often signal new or evolving physical, cognitive, social, and
emotional development and represent peak times of vulnerability to various risk factors.
Prevention interventions are designed and tested for specific stages of development, with a
focus on fostering optimal development as the child encounters new internal and external
capacities, social relationships, and contexts. For instance, the expectations for
performance associated with new phases of life can trigger anxiety and self-doubt among
many children. Providing experiences with and practice in negotiating new situations
during these transitions can foster confidence and competence, thereby maximizing the
potential for optimal development.
As was described in “Intervening in Early Childhood,” interventions are generally targeted
to the context that is most central to the target population—the proximal context. The most
important context of very early development is the family, and thus this is the focus of
prevention interventions for the prenatal through infancy and toddlerhood periods.
Interventions may be delivered in the home or in other contexts with which families
interact.
**
Other contexts, like school, become increasingly important for children at older
ages.
Intervention components specify what knowledge, skills, and competencies are addressed
in an intervention to achieve the target outcome. Components are specific to target
populations and, within an intervention, multiple actors may be defined as target
populations. For example, family-based programs often include parent and child behavioral
outcomes and classroom interventions often include both teacher and child outcomes.
Moreover, interventions that combine contexts—such as family and school—could target
the child, the caregivers, and the teachers. Thus, the targeted knowledge, skills, and
competencies would be specific to those intervention populations and can be very precisely
defined.
**
This is the case with two examples of the NIDA-supported interventions for children under the age of 3.
The Nurse Family Partnership intervention (www.nursefamilypartnership.org) sends nurses to the home
to train young mothers and can take advantage of the public health system for implementation. The Early
Steps intervention screens for mothers in need of services through an existing program for at-risk families
called Women, Infants, and Children (WIC), who are then visited, usually in the home, by a trained
clinician. Together they decide what resources and services would be most helpful for the child and
family.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 81
The diagram “How Interventions Work” illustrates several key features that help in
understanding how interventions work. Moderators are aspects of the people who are
targeted by the intervention and influence the intervention’s design and outcomes but
cannot be changed—such as age, sex, race, and socio-economic factors such as poverty.
Modifiable risk factors are the knowledge, behaviors, attitudes, intentions, skills, and
competencies that the intervention attempts to change. The intervention often includes:
• activities designed to promote skill development in specific areas such as parenting
• environmental change strategies, such as modifying classroom management style to
reduce the aggressive behaviors of some children
• provision of services to help in the development of specific competencies such as
academic skills through tutoring
• community-level change strategies such as changing minors’ access to alcohol or
tobacco through policy enforcement
Program Evaluation and Assessment of Benefit-Cost
Prevention interventions developed using scientific methods go through these stages of
theory and logic model conceptualization. In addition, they are subjected to testing, usually
in a randomized controlled trial (RCT) or other rigorous research design. An RCT randomly
assigns participants to intervention and control conditions. The advantage of this method
and other rigorous research designs is that they make it possible to draw conclusions about
the effectiveness of an intervention without being concerned that the outcomes are related
to some other population or contextual factor that was not taken into account.
Through the evaluation and comparison of measures of current status among intervention
and control group participants at multiple time points before, during, and after the
intervention, changes in behaviors, attitudes, intentions, skills, and knowledge can be
assessed to determine if the expected positive results were achieved.
Continued assessment of intervention-group children and families and comparison with
control-group families into adolescence—and in some cases, into early adulthood and
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 82
beyond—allows researchers to draw conclusions about the impact of intervening in early
childhood on outcomes across the course of development, including effects on the initiation
or reduction of drug use and related problems. Long-term follow-up of study participants
informs understanding of program effects and provides information that can be used to
determine the benefits of early interventions relative to their costs. Some of the existing
research has not yet been able to follow participants to the point at which drug use, abuse,
and addiction occur; for such programs, the assessment of benefit-cost must be estimated.
Participants in other programs have been followed into adolescence and young adulthood,
and researchers have been able to directly measure outcomes such as drug involvement,
educational attainment, criminality, mental health problems, and health-risking sexual
behaviors. When this is the case, a direct comparison of those who received an intervention
versus those who did not receive it can determine the benefit-cost of the program in
preventing negative and promoting positive outcomes (see “Benefit−Cost Examples for
Early Childhood Programs”).
Infancy and Toddlerhood
Program
Economic Analysis Information
Durham Connects
Cost of the intervention; benefit-cost analysis; Emergency health
care service savings (Dodge et al., 2013b)
Early Steps, Family
Check Up
N/A
Family Spirit
N/A
Nurse Family
Partnership
Savings in government spending (Olds et al., 2010)
Benefit-cost analysis (Karolyv et al., 2005; Aos et al., 2004)
Benefit−Cost Examples for Early Childhood Programs
Research on the benefits relative to costs of early childhood prevention interventions has
shown positive results. Some examples of benefit-cost data of interventions with long-term
follow-up data are:
• Durham Connects—$3.02 saved for each dollar invested (Dodge et al., 2013b)
• Nurse Family Partnership—$2.88 saved for each dollar invested (Aos et al., 2004)
• Seattle Social Development Project—$3.14 saved for each dollar invested (Aos et al.,
2004)
• Good Behavior Game (used in the Classroom-Centered Intervention)—$25.92 saved
for each dollar invested (Aos et al., 2004)
Other programs with long-term follow-up data have not shown benefits this dramatic.
However, the listed examples point out the extent to which a well-conceptualized and
implemented intervention for very young children can benefit society tangibly, not to
mention the improved quality of life for children and families that comes from preventing
substance abuse and other problems. The tables below indicate which of the early
interventions included in this review have economic analysis information (e.g., cost, benefit-
cost, or cost effectiveness analysis).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 83
Preschool
Program
Economic Analysis Information
Incredible Years-Spirit
N/A
Multidimensional Treatment
Foster Care for Preschoolers
N/A
Transition to Elementary School
Program
Economic Analysis Information Available?
Caring School Community
Program
N/A
Classroom-Centered
Intervention (Good Behavior
Game)
Benefit-cost analysis (Aos et al., 2004; Miller & Hendrie,
2008)
Linking the Interests of Families
and Teachers
N/A
Raising Healthy Children
N/A
SAFEChildren
Cost of program(National Registry: SAFEChildren, 2014)
Seattle Social Development
Program
Benefit-cost analysis(Aos et al., 2004; Miller & Hendrie,
2008)
Early Risers "Skills for Success"
Risk Prevention Program
Cost of program(National Registry: Early Risers, 2014)
Kids in Transition to School
N/A
Fast Track Trial for Conduct
Problems
Cost of conduct problems (Foster & Jones, 2005)
Cost effectiveness analysis (Foster et al., 2006)
Incredible Years
Cost effectiveness analysis (Foster et al., 2007)
Positive Action
Cost of program(National Registry: Positive Action,
2014)
Schools and Homes in
Partnership
N/A
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 84
Selected References
A
os S, Lieb R, Mayfield J, Miller M, Pennucci A. Benefits and costs of prevention and early
intervention programs for youth. O
ly
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Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 85
Determining Community Risk and Protective Factors
Before selecting a prevention program or developing a comprehensive plan, it is important
for communities to determine what risk factors may be contributing to problem behaviors
and what resources the community has available to address the problem(s). Assessment of
risk and protective factors is used to identify the problem(s) of interest through archival
searches for information available in existing community databases (e.g., poverty level;
access to nutritious food and health care; child accidents and maltreatment;
abandoned/substandard housing; access to alcohol, tobacco, drugs, and firearms; toxic
exposure) and through surveys of community members to assess family, school, and
community functioning. Assessing these factors can help identify the most pressing
problems facing a community. Community prevention leaders can then select the targeted
problem to intervene upon (see “Examples of Community Risk Assessment”).
Examples of Community Risk Assessment
Below are two examples of risk and protective factor assessments at the school and
community levels. The first example shows the results of surveying students within a high
school about specific risk and protective factors. The resulting bar charts provide
information on factors that can then be matched to specific evidence-based interventions.
In this particular example, community coalitions identified specific factors that needed to be
reduced (risk factors; top graph) or increased (protective factors; bottom graph) and
selected evidence-based prevention interventions to address them. The graphs illustrate
how communities compare with the average for all schools within the school district and
the national average on measures of protective factors at the community, family, school,
and peer-individual levels. As shown in the top graph, for High School ‘N,’ ratings for several
risk factors are significantly higher than those for other schools in the school district and the
national average; the community selected one of these, “Favorable attitude toward drug
use,” as the risk factor they wanted to work on decreasing for this school (yellow arrow). As
shown in the bottom graph, the value for the protective factor “Social skills” in High School
‘N’ was found to be a significantly lower compared to ratings for other schools in the school
district and the national average, and the community selected this as the protective factor
they wanted to work on increasing for that school (yellow arrow).
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 86
This framework could be adapted for use with early interventions. For example, data could
include archival measures of public health data on prenatal visits by mothers, birth weights,
social service records on child abuse and neglect, and access to local and county support
services. Risk and protective factors could be determined through national data sets that
provide information at the community level as well as by parent reports of child and family
behaviors.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 87
S
ource: Hawkins, JD. Preventing Teen Smoking, Drinking and Violence Community Wide: Results
from the Randomized Trial of Communities That Care. Division of Epidemiology, Services and
Prevention Research (DESPR) Seminar, National Institute on Drug Abuse, Rockville, MD; 2011.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 88
Identifying the Target Population
Identifying the subpopulation most impacted by the problems isolated through the
community assessment of risk and protective factors will help determine the population to
be targeted for intervention. The target population is defined based on characteristics of
the individuals or group to be addressed by the intervention. For interventions addressing
childhood problems, age or developmental period is usually the most important defining
characteristic. Other characteristics to consider in defining the target populations include:
gender, race/ethnicity, health status, and socio-economic status. Another significant
defining characteristic of target populations is level of risk. Risk assessments help in
defining individuals and subpopulations at elevated risk due to internal, behavioral,
familial, and environmental factors.
The second example provides a representation of substance abuse risk and protective
factors within a geographic community area. Based on youth surveys and community
records, 23 risk factors and 10 protective factors were examined in three neighborhoods of
a California community. The peaks within the three neighborhoods in the figure below
indicate elevated risk, with neighborhood #2 showing the highest elevation of risk factors.
Communities can use this information to decide where to implement evidence-based
substance abuse prevention interventions in order to address specific risk and protective
factors.
Geomapping Based on Risk Assessment
Source: Hawkins JE, Catalano RF, Arthur MW. Promoting science-based prevention in communities.
Addictive Behaviors. 2002;27(6):951-976. Copyright ©2002, Elsevier Science Ltd. Reprinted with
permission.
Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide 89
Adapting Programs
One question that is sometimes asked is whether childhood prevention interventions need
to be modified for implementation with populations or contexts that differ from the
original research. Unfortunately, this question has not been adequately addressed through
research. Minor changes to original program materials to make the people, contexts, and
examples more relevant to a specific group have been found to have little effect on
intervention outcomes. Generally speaking, significant changes to the intervention
structure and content are not recommended, as there is limited evidence on how these
types of changes will affect outcomes. When a target population or context differs markedly
from those targeted in available science-based interventions, a new intervention tailored to
meet that population’s specific needs (e.g., cultural or contextual needs) may need to be
designed. An example of one such program, Family Spirit (described in “Research-Based
Early Intervention Substance Abuse Prevention Programs”) intervenes with very young
poor mothers on American Indian reservations (Barlow et al., 2006).
Another adaptation that may need to be made is providing program support services to
participants to make an intervention more accessible to them. Services may include
transportation, care for other children in the family, snacks or meals, and compressed
programming (e.g., offering fewer but longer sessions). Accommodations can lessen the
burden associated with attending a program, help to build social support among members
of the intervention group, and help keep participants coming to the program.
Collecting Data
Collecting data before, during, and after the evidence-based intervention is implemented at
the local level is important as it allows the implementer to assess whether the intervention
is producing effects similar to those in the original research and, if not, to help in
determining why. It helps community prevention leaders as they decide on next steps in
maintaining the focus on the most important risk factors to address for developing a
comprehensive prevention plan.
Selected References
Barlow A, Varipatis-Baker E, Speakman K, et al. 2006. Home-visiting intervention to improve child
care among American Indian adolescent mothers: a randomized trial. Arch Pediatr Adolesct Med.
2006;160(11):1101-1107.
