Studies of Substance Abuse with Interventions for the Youth of Native American Indian Community #14

CHAPTER 2: Review of Related Literature

The recognition that substance use among American Indian youth often begins at an early age has resulted in a growing emphasis on prevention rather than treatment efforts. Research detailing epidemiology, etiology, and domains of risk and protection can provide the basis for developing prevention programs and identifying intervention targets. These preventive interventions are designed to reach children early and limit the initiation of substance use and/or the later development of substance abuse and related consequences.

Prevention services are widely characterized as primary, secondary, or tertiary (Caplan, 1964). Within the health field, primary prevention programs are aimed at reducing the incidence of a particular disorder or risk factor. Secondary prevention programs target early identification and treatment to reduce the prevalence of a particular problem. Tertiary prevention programs focus on reducing the severity or impact of an established condition. Because this framework assumes dichotomous categorization (i.e., present and absent), using this classification system often makes it difficult to distinguish between primary and secondary prevention. Instead, mental health and substance abuse problems tend to be conceptualized as spectrum disorders, with attention focused on the level and severity of functional impairment rather than the strict presence or absence of a disorder.

In 1994, the Institute of Medicine proposed a new model that divides the continuum of care into three categories: prevention, treatment, and maintenance. The prevention category distinguishes between three classifications of prevention programs: universal, selective, and indicated. In a universal program, specific individuals are not singled out for an intervention; rather, all individuals within a defined area or population are offered the service. Examples of this include high school health education classes and anti-smoking media campaigns. Selective prevention targets groups of individuals considered at higher than average risk because of the presence of one or more risk factors. A program designed for children of alcoholics or an after-school mentoring program for youth experiencing behavioral problems are examples of selective prevention. Indicated prevention programs are aimed at specific individuals who have already begun engaging in high-risk behaviors but who do not meet criteria for a substance use disorder. Examples of this kind of intervention might include youth screened for problems at school or a physician’s office, or those mandated to treatment. Selective and indicated preventions are also often referred to as forms of targeted prevention.

Universal and targeted prevention programs both have their advantages and disadvantages (Offord, 2000). Universal programs tend to cast a wider net and can, therefore, potentially influence more people. They also tend to be less stigmatizing, as no one individual is singled out for attention. However, they are often expensive usually have a smaller effect on any one person, and may have the greatest effect on those at lowest risk. Targeted programs have the potential advantage of efficiency, as available resources are directed only at the high-risk group. In addition, they tend to be more intensive and may have greater impact on an individual level. A common difficulty in indicated interventions, though, is the cost and commitment necessary to screen individuals to determine risk status. Furthermore, risk factors are usually fairly weak predictors of future pathology, so screening may not accurately target individuals in the most need. Finding the balance between sensitivity (the ability to accurately detect those who are at risk) and specificity (the ability to correctly identify those who are not at risk) often presents a challenge for clinicians and researchers.