Experts say prevention key to healthy development

When J. David Hawkins was a probation officer in the 1980s, he thought, “Isn’t there something we should have done to prevent these kids from getting to this place?”

a line of smiling young children with their arms around each others shouldersPrograms from that period, like “Just Say No” and “Scared Straight,” just didn’t work, he said, for one reason: There was no evidence behind them. 

Now Hawkins is part of a large interdisciplinary group of experts who envision a future where all youths can grow up free from emotional and behavioral problems, and they are backing up that vision with more than 30 years of tested and proven research to get us there as they address the American Association of Social Work and Social Welfare’s Grand Challenge for Social Work to ensure healthy development for all youth.

“We understand how to prevent developmental health problems,” said Hawkins, Endowed Professor Emeritus of Prevention at the University of Washington School of Social Work in Seattle, where he is founding director of the Social Development Research Group.

He is co-leader of the Grand Challenge. “If we want to promote the health of the next generation and their economic development, we need to take advantage of these proven studies,” he said. “We now have the power to unleash the power of prevention.” 

Prevention First

J. David Hawkins

J. David Hawkins

“As a society, we’ve actively responded to these grand challenges,” said Kimberly Bender, professor at the University of Denver Graduate School of Social Work, where she is associate dean for doctoral education.

She is co-chair of the Grand Challenge workforce development group.

“Ours is about preventing problems before they start,” she said. “Individuals and families would suffer less if we prevent them before they start, and it’s usually more cost effective for society.”

Jeffrey M. Jenson, a challenge co-leader, pointed to the opioid addiction problem as one example, because childhood prevention programs have shown fewer use drugs later on.

“True preventive interventions should be much more at the core of human and social services in the U.S.,” said Jenson, the Philip D. and Eleanor G. Winn Endowed Professor for Children and Youth at the University of Denver Graduate School of Social Work.

He is an AASWSW Fellow and serves on its board of directors. “There is sufficient evidence that prevention definitely can make a difference,” he said. “We’re trying to change the indicators in population health. We’re interested in trying to move the needle at the population level.”

The political dial also needs to be moved to get more attention on prevention, rather than dealing with it afterward, said Richard F. Catalano Jr., Bartley Dobb Endowed Professorship for the Study and Prevention of Violence and professor at the University of Washington School of Social Work in Seattle, where he is also an adjunct professor of sociology and education. 

He is co-founder of the Social Development Research Group at the school, and currently is a member following tenures as associate director and director.

“It’s important to reduce the uptake of opioids, reduce it by one-third or 50 percent, as some interventions do,” he said. “To use an analogy: You can channel the water flowing out of a water hydrant, but wouldn’t it be better to turn off the faucet? All problems are like that.” 

Professional Collaboration 

Hawkins said there are many reasons for an interdisciplinary approach to prevention.

“There are a number of tested and effective programs for parents with children ages 2, 3, 4, up through adolescence, but hardly anyone goes to them because they think there’s a stigma involved,” he said.

Many think others will view them a bad parent, or they don’t believe others know more about parenting than they do, Hawkins said. We can solve that problem if programs are incorporated into regular primary care.

If a parent goes to the pediatrician and mentions a problem, the doctor can say “we have a program for that.”

“Evidence shows parents go to these programs in higher numbers than if it’s in a school or community center,” he said. “For the greatest reach and the greatest effect, we have to collaborate with other professionals.”

School failure, mental health issues, violence and other behavioral problems show up in different sectors, said Catalano, who heads the challenge’s funding work group.

“Behavioral problems in different sectors require sectoral collaboration,” he said. “School failure, mental health problems, violence and other problems command different expertise areas. We need to activate doctors, psychiatrists, counselors, schools, teachers to use prevention in their settings.”

Kim Bender

Kim Bender

“Folks in policy roles in states need to be activated and included if we’re going to implement evidence-based prevention and obtain federal and state monies for prevention.”

Bender said prevention is not focused on one issue, it’s trying to zone in on wellness.

“Public health has been working in prevention for a long time,” she said. “Nursing has been at the table. Prevention uniquely unites disciplines — it’s a group problem. That takes cross-training so social workers are prepared for those roles. We’re well suited because we’re trained to work across systems.”

Jenson said because of that cross context, “it’s important that we prepare social workers with what is known about prevention so they can forward that evidence and knowledge into the discussion as well.”

That means everyone must have a seat at the table. 

Organized for Action

When the AASWSW in 2013 sought input and called for ideas for their Grand Challenges Initiative, Catalano said he, Hawkins, Jenson and Bender were prepared.

“We created a coalition to move this grand challenge forward,” he said. 

He and many others already had been working on prevention research for years, some since the early 1980s.

“Research groups across the country contributed to this knowledge base,” Catalano said. “When the Grand Challenges happened at the Summer Institute, we thought prevention was something that would be natural for the Grand Challenges. We were poised.”

Hawkins, co-lead with Jenson on the grand challenge and leader of its membership and outreach group, said it’s not enough to tell people that reducing factors in the environment are needed.

Social protective factors for prevention are necessary, along with organizing what is known about them. People also were organized.

A large interdisciplinary group was gathered to form The Coalition for the Promotion of Behavioral Health.  

The Institute of Medicine of the National Academies published the coalition’s discussion paper, “Unleashing the Power of Prevention,” in 2015.

Jeff Jenson

Jeff Jenson

The coalition works to forward the goals of the Grand Challenge, said Jenson, who leads the challenge’s dissemination of Unleashing the Power of Prevention working group and chairs the steering committee, a smaller group within the coalition.

The steering committee helps pull others into the coalition to “help us move the activities of the whole Grand Challenge,” he said. 

Hawkins said it also broadens the reach of the Grand Challenge group. Members are aware of what is going on in their own disciplines.

They know of various professional gatherings and can arrange for challenge members to speak at them, widening the outreach through their own associations, he said. 

Blueprints for Success 

Many very early prevention ideas were not very effective because they did not intervene with risk factors, Jenson said. “One, for example, was how well parents manage their children’s bed times or the quality of parental supervision,” he said.

Hawkins said “It’s not just one program that is the silver bullet in prevention.”

Richard F. Catalano Jr

Richard F. Catalano Jr.

The number of students involved is important, and a program must be tested two times and have follow-up later, he said. “Most are well-validated and well-replicated.”

One example is a study he and Catalano conducted through the Social Development Research Group on how to prevent youth violence.

“We’re still collecting data on those kids who were in the first grade in 1981,” Catalano said. “Now, they’re 40 years old.”

The study sought to find what the developmental level for the children was and how to strengthen it. It involved parents, teachers and home and school settings, he said, and was designed for teachers to use better classroom management and parents to use behavioral management techniques at home.

Classroom rules were: No one would be embarrassed, no acting out, and all would be on task. There were routines for entering the classroom, transitions and what would be done if someone began to act out, Catalano said.

The strategies promoted included teachers motivating students to learn through interactive practices to get them engaged, “making sure they get it, and harnessing peer influence for learning,” he said. “We were not changing the kid, we were changing teachers’ practices and how they managed the class and taught,” Catalano said.

Parents were taught behavioral management techniques to use at home, he said. “They were the same principles, pinpointing reinforcement of rules and how to support their kids’ academic success,” Catalano said. 

In all six grades of the primary school, children were taught cognitive skills, cooperation, friendship and problem-solving skills. Students at the end of primary level also were taught refusal skills so they could stand up to things like peer pressure.

“We saw a lot of changes, a lot of things happen — not only during primary school, but after,” Catalano said. “We looked at kids over time.”

The findings included greater academic performance and reductions in conduct problems, violence, substance abuse, symptoms of mental health problems and diagnoses of any mental health problems, he said.

“By age 21, we found half the rate of high school dropouts and more were attending college,” Catalano said. “By age 22 to 27, more had accessed higher education, more had increased household income and fewer had mental problems.”

The teaming up of parents and schools produced broad, wide-spread effects, he said. “We also saw the complete elimination of disparity in health problems in African Americans,” Catalano said. “That’s the strength of preventions at that time period.”

There are other studies that have found it’s never too early, or too late, to do prevention, though some have found earlier ones have a greater effect,” he said.

Jenson said there are a host of programs found to effective, and “Blueprints for Healthy Development is a good source.” 

Workforce Development 

The over-reaching goal is to prepare a social work prevention workforce with an interdisciplinary lens that works with other disciplines in a prevention emphasis, Bender said. “That’s our vision moving forward.”

“If you think level, prevention is macro level,” she said. “When you think treatment, you think of how to get at the root of the problem, and how to attack it before the problem happens is upstream. 

“Every time you teach about intervention, you need to teach about prevention,” Bender said. “There’s a lot of overlap with what social work students are already learning, but what’s needed is prevention skills. We’d like to get our workforce prepared to do that work.

Currently, she said, prevention is all focused at the master’s level. But a small group of social work educators across the country is honing in on developing modules that shift the prevention framework into bachelor-level studies during the foundation year. 

In addition, “a lot of states have schools that offer prevention certification,” Bender said. “Others focus on training practitioners already in the field.”

“It’s a paradigm shift for social workers. I sometimes feel the need for a PSA (public service announcement) on why it’s needed every time I teach about it. I think the barriers are part of our own frame of what social work should be.”

The biggest challenge right now is thinking of this huge field of prevention and breaking it down into small bites and figuring out how it can be implemented and overlaid into social work key competencies, she said. 

“Narrowing it is a challenge,” Bender said. “It feels like we’ve bitten off a small piece of it.”

One immediate step is “how to map our own work on education and training. Then, how to provide CEU training for BSW students,” she said.

Farther ahead, she’d like to see a prevention foundation at the master’s level wrapping up not just in the classroom, but “giving students the opportunity to practice in the field with field supervisors in the prevention area.”

In 2014, Bender and Jenson published the book “Preventing Child and Adolescent Problem Behavior: Evidence-based Strategies in Schools, Families and Communities.”

“It’s lots of meta analysis,” she said. “There’s such a big body of literature, and it’s evolving not only in quantity, but in quality.”

And some social work educators are honing in to develop modules that shift the framework toward prevention, Bender said.

“This grand challenge is really an exciting initiative because it’s forced us to address key changes as a profession,” she said. 

The biggest challenge to reaching their goal is getting communities to invest resources in prevention “when the best outcome is nothing happens,” she said. “It’s a little harder to convince the public there’s a need and resources are needed to prevent something from happening. Prevention actually has a lot of cost benefits later on, but it’s hard to convince people of that.” 

Funding Challenge 

The history of prevention funding and enforcement funding shows one big challenge.

From 2007 to 2015, 15 billion dollars was spent on law enforcement to stop drugs from coming in and to lock people up, while less than 1 billion was spent on prevention, Hawkins said.

“We don’t invest in prevention because it’s not a crisis,” he said. “We want to declare everything an emergency before there’s money spent on it.”

Opioid abuse still is mainly a policing and treatment problem.

When it comes to prevention, “if there’s no disorder, there’s no code for that,” Hawkins said. “Interest in prevention is wonderful, but we have to change payment systems to pay for prevention.”

Funding also is a challenge when it comes to pushing the prevention initiative, said Catalano, who leads the funding groups for the both the working and steering committees. “One of the biggest challenges to our goals is we need a significant investor in promoting prevention,” he said. 

The tendency with government funding is toward high-end treatments, like with the opioid epidemic, where monies are put into treatment and life-saving drugs, Catalano said.

“Politically, if it bleeds, it leads,” he said. That is unfortunate because financial and human costs are less if things are prevented before they occur, Catalano said, and “that doesn’t get as much political attention.” 

Getting the Message Out 

Jenson is trying “to move the needle” at the federal level through working at the state level as he leads the steering and working groups’ goals of disseminating information to convey the message and goals of the challenge.

“There are certain federal dollars sent to states for a variety of purposes,” he said. “I’d like to see a higher percentage of that going toward prevention.”

Jenson is working with states, meeting with their officials and convening with people to urge improving the infrastructure of delivering prevention programs, boosting workforce development and implementing prevention in primary care settings. 

“Those three areas we’re putting a lot of energy into, and we will continue those efforts,” he said.

Jenson’s university hosted a Grand Challenge event in October — one of a Grand Challenges for action series.

“We’re trying to bring the Grand Challenge to the public,” he said. “It was billed as a celebration of prevention.” More than 200 people attended, including Colorado Gov. John Hickenlooper, who also spoke at the event.

The program was videotaped and can be seen online. “That shows what we’re doing,” Jenson said. 

Leading the Way

Social workers are the right group to lead this Grand Challenge, Hawkins said.

“If you look at the roots of healthy behavior and risky behavior, it’s really advanced as a field that came from social work,” he said. “Because of social workers’ success in addressing both policy and practice, it’s a good fit.”

Bender agrees.

“We’re systems thinkers,” she said. “We’re strong advocates, and we pull together stakeholders like families and schools. We’re the bridge that reaches out to communities.”