[Episode 57] Today's Social Work Podcast is on community-based prevention services for children and adolescents. I spoke with Dr. Richard F. Catalano, who along with J. David Hawkins, developed Communities That Care, a prevention-planning system that promotes the positive development of children and youth and prevents problem behaviors, including substance use, delinquency, teen pregnancy, school drop-out and violence. It is a system for identifying community needs, matching those needs to evidence-based prevention programs, and evaluating the outcomes. The system has been used in dozens of communities around the United States, and has demonstrated effectiveness in reducing problem behaviors and promoting positive youth development.
Download MP3 [30:47]
But before we get to the interview, I want you to imagine for a moment how you would work with a pregnant 16-year old sexual abuse survivor who was addicted to crack, semi-illiterate, suicidal, diagnosed with bipolar disorder, and whose baby daddy was prostituting her in exchange for drugs. Ok, got your treatment plan figured out? If you’re thinking, "I know I need to address her suicidality first, but after that, I’m not really sure," then you’d be right, and you’re probably not alone. Most social workers, most service providers, treat individual or family problems once they’ve occurred. And this young woman has a lot of problems. So, what if I suggested that the best place to start with this client was 17 years ago, before she was born, before she was raped, before she turned to drugs to dull her pain or perhaps used drugs to make herself look cooler to her father-figure boyfriend pimp? What if I suggested that the best use of time and money was in preventing these problems from occurring in the first place? If you’re with me on this one, you’re not alone.
In 2006, the New Yorker published an article by Katherine Boo (2006, Feb 6) called "Swamp Nurse." The story takes place about an hour southwest of New Orleans, Louisiana, a place where infant mortality, illiteracy rates, and child poverty are among the highest in the country. The title, Swamp Nurse, refers to a group of nurses who do home visits with low-income women during pregnancy and work with them until their child turns two. These nurses are expected to, and I’m not making this up, reduce infant mortality, illiteracy rates and child poverty, and in turn improve the overall health, education, and economic self-sufficiency of these families and consequently the community as a whole. Uh huh. All through home visits. I know. And the most remarkable part? They did it, more or less. How? They were part of a decades-old prevention program called the Nurse-Family Partnership (www.nursefamilypartnership.org/About/What-we-do). These nurses promoted the use of prenatal care, healthy eating, not using cigarettes, alcohol or illegal drugs. They worked with parents to provide responsible and competent care – and to a 16 year old that might include getting them to understand that it is their job to make their baby feel loved, not the other way around. And they helped the parents plan for their future, including future pregnancies, education, and jobs. This program works because it prevents certain behaviors by promoting others. That is the essence of prevention programs. And, according to Dr. Catalano, there are tons of effective prevention programs out there. The trick is to figure which ones are right for your community.
Benjamin Franklin famously said, "an ounce of prevention is worth a pound of cure." This idea, that prevention is a better value for the money that cure, is at the core of public health policy and one of the most compelling arguments for investing in prevention services. Steve Aos, associate director of the Washington State Institute for Public Policy has done cost-benefit analyses on dozens of prevention programs, and found that while most programs do not have a 16:1 return ratio, there are many programs out there that return $3 and $4 dollars per dollar invested. Oh, and the Nurse-Family Partnership? $2.88 per dollar. Steve and his colleagues calculated that by spending $9100 per mother, the Nurse-Family Partnership produced over $26,000 in benefit (www.wa.gov/wsipp).
Let’s come back to our 16-year old crack addicted suicidal prostitute for a minute. If she had been involved with a program, or a series of programs that promoted parent-child bonding, emotional, cognitive, behavioral and moral competence, self-determination, belief in the future, and half a dozen other concepts that are included under in the broad heading of positive development, it is likely that she would have never become my client.
In order to learn more about how this might happen at a community level, I spoke with Dr. Richard Catalano, or "Rico" as he asked me to call him. Rico is the Bartley Dobb Professor for the Study and Prevention of Violence and the Director of the Social Development Research Group in the School of Social Work at the University of Washington. He has published over 225 articles and book chapters, and his work has been recognized by practitioners; criminologists; and prevention scientists.
I asked Rico to talk about some of the persistent problems that youth in America face and why we haven’t been able to overcome them. He talked about why he went from being a treatment researcher to a prevention researcher. We talked about the benefits of taking a community-based approach to prevention. Rico described the Communities That Care prevention system, and talked about what makes it an effective approach to preventing adolescent behavior problems and promoting positive development of children and youth. I interviewed Rico at Temple University’s School of Social Work. He was the invited speaker for the school’s lecture series on social work research. For more information about Temple’s School of Social Work, or the research lecture series, please visit their website at www.temple.edu/ssa.org
And now, without further ado, on to episode 57 of the Social Work Podcast. Communities that Care: Interview with Dr. Richard Catalano.
Download MP3 [30:47]
Jonathan Singer: So, Rico, thanks so much for being here and talking with us today. My first question is, what are some of the persistent problems that youth in America face and why haven’t we been able to overcome them?
Richard Catalano: Youth in our communities today are facing a number of problems. Things like substance abuse, youth violence, delinquency, teen pregnancy, school dropout, these problems have persisted over time and have been particularly difficult to change. There are some new directions that actually have had effects on these but overall our communities, particularly in this time of economic downturn, are plagued by these problems.
Jonathan Singer: So, why address these kinds of problems through prevention rather than treatment?
Richard Catalano: When I began my career in both research and program development, I really was working on the treatment and remediation side of the equation. Many of the children and adults that I worked with had already experienced the reinforcing effects of drugs, they were often failing at school, they were in serious conflict with their families, and, if they were adults, they were actually leading a whole new generation down that same path. It’s important work that has to be done, working in treatment and aftercare and remediation. The problem is that a lot of damage has been done, both to the kids themselves, their families and their peers, as well as incredible costs to society. So we kept thinking, wasn’t there something we could do other than just run an ambulance service at the bottom of a cliff underneath a sharp curve? Wasn’t it possible to put up guardrails so kids wouldn’t go careening off when they came to that sharp curve? Or even better yet, couldn’t we step back further and put up signs that said, “Danger ahead, please slow down”? Or even better, couldn’t we work with kids before they ever got in the car and provide good drivers’ education and training so they could recognize the signs of dangerous driving situations? Or even better, couldn’t we create laws that would put in graduated driver licensing so that kids would have enough experience before they got their license and they wouldn’t be in the car with a lot of distractions while they’re learning to drive? Or best, couldn’t we do all those things – guard rails, signs, training and education, and policy change at the same time? So I became very interested in taking this approach to prevention to prevent kids from falling over the cliff, if you will, and it’s been an interesting career to make that shift from treatment and aftercare to prevention. The great thing in the single career, when I began my career and started looking into this area, David Hawkins and I did a couple of reviews of what works in prevention and we looked at all delinquency prevention and substance abuse prevention at the time, this was in the mid- to late 70’s, and what we found was that not a single one, not even in the well-controlled studies, not a single one of these interventions worked. But now, thirty years later, there’s a variety of preventative interventions that have been tested and shown to be effective in controlled trials. And we have a range of effective approaches from prenatal and infancy programs to early childhood education, parent training through the developmental span of children in adolescence, programs in schools, as well as programs that affect communities themselves. So it’s really been a big sea change in the prevention area.
Jonathan Singer: Rico, you just mentioned that there are persistent problems that we haven’t been able to overcome and yet, there are now a number of effective programs for addressing issues in youth and possibly in adult populations. How is that possible that we can have programs that work and yet we haven’t been able to overcome these problems?
Richard Catalano: That’s a really good question and I think it’s the 21st century question. We are at a point where we do have effective models, they are distributed across development. There’s two problems, or two parts to this problem. The first problem is that many of these programs have been demonstrated in research studies so those of us at universities have developed these programs, carefully implemented them, and found them to be effective and often many of us are happy by finding that and putting it in a journal article and expecting the world to change. Then when someone says, oh, here’s this effective program, how can I get it? Then they write the author and they say, well, we’ve moved on but we have these three-ring notebooks if you’d like to look at our notes, you could actually try to implement it. Universities really aren’t set up for disseminating usable programs in communities. So one part of the sea changes that has to occur is that those programs that are effective need to be manualized and set up so that real people and real communities, social workers in various systems, can actually deliver those in interventions. And that has changed over the last 15 years when we were starting to do these reviews, most of the studies we found didn’t have this backup but now as federal and state funds have been available for evidence-based practice under that rubric, more and more of these programs are developing those manuals, the training programs that are necessary to actually get programs in wide distribution. The last time I did a review, although there was over 90 programs that have been shown to be effective, only about 40 of those programs actually had training and technical assistance to go along with them. And 10 years before that only about 10 did. So it’s really been that part of the sea change. And the second part is that we as practitioners and consumers also need to jump on this bandwagon. In Washington State, practitioners are continually coming back to us, and we do our surveys of the field and say, what do you expect of our graduates and what do you want? And they come back to us every time with, you guys could be doing a better job of two things: one, teaching your students to evaluate their own practice, and although we do that, obviously it’s not good enough and the field is demanding it, and teach them more about evidence-based practice and what works where, with whom, and those kinds of things because we really want to know that more. So the field is driving it. But I think we won’t be able to make the difference with these persistent problems until community members, consumers, are demanding these same kinds of things. To tell a personal story, two and a half years ago I had prostate cancer; I was diagnosed with prostate cancer. I wanted to find out everything I could about what the cancer was, what kinds of treatments there were, what the long term results were, what the complications were with different methods of treating that. So I, as a consumer, I was digging into the research literature, while I am probably better placed than most people to do that, on the other hand, it’s available on websites that you can actually, a regular consumer, not a researcher necessarily, can find these things in that field. We’ve got to be in the same place that when someone at your school says, oh, we’re doing this program; we think that the parents should be saying, well, why, and has that been shown to be effective? And if that person stumbles, then they say, well, we really don’t want to do that program, we want to do something that’s effective. Or if they say, yes, it’s effective, then you want to say, well, then how is that demonstrated? Was that demonstrated in a controlled trial or did just Jimmy and Mary do that program and they liked it or not? So we have to be asking those questions and we have to be getting those answers from people who are responsible for helping us raise our children.
Jonathan Singer: So you talked about your own experience as a consumer and you talked about parents and the need for consumers to really be able to find this information and demand it of us as providers. And when I hear that I think about individuals, but your area of expertise and what you’ve been researching is community level approaches to prevention. I’m wondering if you could talk about why you think it’s important to take a community-based approach to prevention.
Richard Catalano: That’s another great question. There are at least two reasons to do this. The first reason is that all communities are different. Communities will tell you that, as a practitioner, oh, we’re different than this other place, West Philadelphia’s different than the North End and communities within that will tell you that they’re different and they are. So one size does not fit all across communities and that’s really an important thing for us to recognize. On the other hand, we need to mobilize all the resources in communities so that we can, in prevention at least, prevention funds and programming are distributed across a number of sectors, criminal justice, education, social and health services, and many other areas. And if we could get those practitioners and consumers to work together, we’re going to have what we really need to do effective prevention. So two things, it has to be done at the local level because we can actually demonstrate that the kinds of problems in different local areas are different and the predictors that are driving those problems are different in each area. That means that different programming solutions are necessary in different local areas. The best advocates for that are going to be the local community members, the local service providers that can actually ensure that the effective programs that they choose are going to be working with their populations. They’re the ones that are going to be most likely to know what their populations react to, they can choose a number of programs. And a neighborhood in West Philadelphia might choose different programs than neighborhoods in North Philadelphia, although they may choose some of the same things because there are similar problems in both communities but there will be differences and there will be cultural or economic differences that may indicate different programs being necessary.
Jonathan Singer: In thinking about communities choosing programs, prevention programs, and tailoring them to the needs of the specific communities really makes me think of the need for local research. Not just sort of local research and how well these programs work in these neighborhoods, but really on the neighborhoods and developing programs within neighborhoods that may or may not work in other neighborhoods around the country.
Richard Catalano: It’s really important to do this neighborhood-based research on two ends. One, for needs assessment because that will help us indicate which types of programs are more important for different areas, as well as on the outcomes of these programs. One of the clear things that we’ve learned in the effectiveness research in prevention is that intervention fidelity is really important to getting the outcomes. If you just say, here’s a five session program and it has these ten things in it and I, as a practitioner say, well I’d like to choose only two session because I just don’t think I can get my population to come out for five sessions, and I only want to do six of the ten things because they’re easier to do or whatever. Those programs are likely not to be effective. So we need research not only on the outcome of these programs but, are they being delivered in the way that they are supposed to be delivered? Now there are adaptations that are for different cultural groups, but primarily, and many of these programs have been tested with multiple cultural groups, but primarily adaptation is involved in how you get people in front of the program? So, how you recruit people is really really important and it’s very different in different neighborhoods, in different cultural, in different economical groups. Low income people have a harder time getting out to a place, maybe you have to take the intervention to them rather than asking them to come to your agency. That’s one area. And the other one is that in order for people to change, the ideas have to make sense to them, therefore you have to communicate it in a way that actually says, “Ah ha! This works for me, I could do this.” As we know, our practice community is very good at knowing what may capture people’s imaginations that say, “Ah ha! This is important for me. I need to make these changes in my family. I need to make these changes in my community.” And those arguments may be very different in different communities. So both of those are necessary on the adaptation level but on the other hand, the program itself really needs to be delivered with fidelity if it’s going to make a difference.
Jonathan Singer: So as you’re talking about what communities need and the variety of programs that are available and all of the components that one would have to consider in making community-based approaches to prevention successful, it seems a little overwhelming like there are so many pieces of the puzzle. You’ve developed a prevention system called Communities That Care. And I was wondering if you could talk about what that is and how that helps communities to tie those pieces together.
Richard Catalano: Great. When I started my career the question was, does prevention work? Now the question isn’t that anymore because there are effective approaches. Now the question is, what’s the best prevention approach or the best set of prevention approaches that will address the needs in my community today? So we don’t have to do them all and we don’t have to address all of the predictors, we have to address the predictors or the needs of our communities that are most elevated in our own communities. So one of the things that we did after developing a number of prevention programs was to say, we don’t know that we need to develop more prevention programs, what we do need to do is develop an operating system, if you will, of communities to be able to choose the right programs for their needs. So if you live in Seattle, you think of Windows as the operating system and you say, what Windows does for me is it helps me do a couple of things. It helps me get to Word because I write papers and it helps me get to PowerPoint because I make presentations. My administrator in my group needs to get to Excel, so Windows helps her get to a program that meets her needs. So that’s what we need to do with communities. Communities need an operating system that get them to the right application package that’ll meet their community needs. So what Communities That Care does, it’s a year-long process, it helps get the right groups of people together in communities. Now there’s been many different approaches to prevention overall or to community development, community organizing, our approach really tries to connect those key leaders in communities that hold the resources in their community, hold the financial resources like mayors, and police chiefs, and school superintendents, and social service directors, etc. and also connect them to the grassroots people who are imbedded in these neighborhoods and communities so that we can both have resources and we can put those resources together with folks who know how to get things done in their community. So we try to educate and train both groups of people, the key leaders in order to say, we’re going to do this, do you buy into it, and if you do, help us get the right individuals on this community team, strong implementers that will be able to make a difference in their community. And when we come back to you with a plan, you’re going to fund it, and do you want to do that or not? So we make those, it’s clearly a choice that we offer the key leaders and most often they accept that challenge. So we educate key leaders, we then educate a community board to do a needs assessment or a risk and protective factor assessment of their children in their communities. We have a survey of sixth, eighth, tenth, and twelfth graders, we’ve developed great visuals to show, what are the risk factors that are most elevated in your communities, what are the protective factors that are most depressed? Then we help those community teams match, first of all, they prioritize, it’s their prioritization process. They figure out which ones they want to address. Then we have what we call our “Prevention Strategies Guide” in Communities That Care that actually shows, if this is your risk factor, here’s a set of different approaches that could address that risk factor. There might be, for instance, parent training in our school curriculum, or community policy change, and then if they choose a particular general approach, there’s actually a list of programs underneath that have good training and technical assistance that have demonstrated outcomes so that they can go dig into the different types of programs and say, this one is the one that will fit with my community, this one I don’t think it will, this one I think we can do. And then we work with them to facilitate their planning for implementation, bringing the training in for the particular approach, and getting these new community prevention programs implemented in schools, in social service settings, and other institutions. Since we did the needs assessment at the front end, it also works, we suggest they do the survey every two years so they can see how well they’re doing and if they’ve made changes in the risk and protective factors and outcomes that they prioritized, as well as there is fidelity assessment for the programs because for some reasons you might not see changes or we’re not doing the program the right way. Another reason is that, well we wanted reach all 300 parents of fifth graders in our community and we only reached 20. So there’s a saturation issue as well so we help communities track both saturation and fidelity to see if those affect their outcomes in the long run. It’s a kind of thermostatic process, Communities That Care, because you’re reassessing all the time so you can see if new needs or new risk factors are popping up. And as you work in some areas reducing risk, other areas may now become priorities because you’ve addressed some of the areas already. So you go into another planning cycle about on an every two to three year basis.
Jonathan Singer: So the question is, how is it that Communities That Care seems to work? What are some of the factors that seem to make it an effective approach to preventing adolescent behavior problems and promoting positive development in children and youth?
Richard Catalano: You know, we’ve done a randomized trial of 24 communities across 7 different states: Washington, Oregon, Utah, Kansas, Illinois, and Maine, and Colorado, and what we’ve found from that is that our theory of change actually has been shown to be the way that it happens. If you give training and technical assistance to communities, there’ll be some things that happen at the community level. First of all, they’ll adopt this kind of science based approach to prevention, and I don’t just mean the teams or the other individuals but we can ask many different people in the community, what’s going on? Indeed we’ve shown that that has happened. The second thing that happens, not only do they adopt this approach if we do the training, but they actually collaborate more. So there’s a lot more interagency collaboration, there’s a lot more collaboration between key leaders and prevention programmers at the ground level, the key leader’s involved and informed about what their progress has been. So there’s really a lot more collaboration, innersectoral collaboration, that happens. The third thing we think would happen, if those two things are happening, because this is an evidence-based approach, we think there should be more evidence-based programs in communities and, of course, there are. And not only are there more evidence-based programs, everyone’s pushing for that now, but the evidence-based practices are delivered with high fidelity to the idea of the intervention. And how we’ve done that is in very interesting ways. As the community board chooses these programs and they train the individuals to do it, the community board members are responsible for watching the implementers deliver the program, so they have little fidelity checklists as well as the implementers have them, but they’re there and saying, oh look, this is what we’ve decided to do, and look they’re doing it the right way, isn’t that great? So they provide feedback to the implementers as well. So we also get it with high fidelity. Our timeframe is about, after implementing the program, between one and two years we expect to see changes in the needs or the risk and protective factors. We actually have seen that demonstrated that that happens in this trial. And after three to four years we expect changes in outcome behaviors and we’ve seen changes in substance abuse and delinquency among children in these communities in our trial.
Jonathan Singer: Rico, thanks so much for taking the time today to talk with us about Communities that Care.
Richard Catalano: Thanks, it’s been great to do the podcast. Thanks, Jonathan.
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Dr. Richard Catalano firstname.lastname@example.org is the Bartley Dobb Professor for the Study and Prevention of Violence and the Director of the Social Development Research Group in the School of Social Work at the University of Washington. He is also Adjunct Professor of Education and Sociology. He received his bachelor's degree in Sociology from the University of Wisconsin, and his masters and Ph.D. in Sociology from the University of Washington. For 30 years, he has led research and program development to promote positive youth development and prevent problem behavior. His work has focused on discovering risk and protective factors for positive and problem behavior, designing and evaluating programs to address these factors, using this knowledge of etiology and efficacy to understand and improve prevention service systems in states and communities. He has published over 225 articles and book chapters. His work has been recognized by practitioners (1996 National Prevention Network's Award of Excellence); criminologists (2007 August Vollmer Award from the American Society of Criminology, 2003 Paul Tappan Award from the Western Society of Criminology and Fellow of the Academy of Experimental Criminology); and prevention scientists (2001 Prevention Science Award from the Society for Prevention Research).
He is chair of the Washington State Epidemiological Workgroup and a senior advisor to Active Living Research, a program of the Robert Wood Johnson Foundation. He has served as chair of the National Institutes of Health, Risk, Prevention and Intervention for Addictions Review Committee and as chair of the Robert Wood Johnson Foundation Free To Grow Evaluation Advisory Panel; as a member of the NIDA Blue Ribbon Panel on Health Services Research, the Office of National Drug Control Policy Evaluation Committee, U.S. Attorney General's Methamphetamine Task Force, Office of Juvenile Justice Delinquency Prevention Study Group on Serious Chronic and Violent Offenders, the CSAP Prevention Enhancement Protocol System for Family Programs, the National Academy of Sciences Panel on Evaluating Needle Exchange and Bleach Distribution programs, and the National Institute on Drug Abuse Epidemiology and Prevention Review Committee. He is the co-developer of the Social Development Model; the parenting programs "Guiding Good Choices," "Supporting School Success," "Staying Connected with Your Teen," and "Focus on Families;" the school-based program, "Raising Healthy Children;" and the community prevention approach, "Communities That Care."
References and Resources
Boo, K. (2006, Feb 6). Swamp nurse. New Yorker.
Catalano, R. F. et al. (1999). Defining Positive Youth Development Constructs. Retrieved from http://aspe.hhs.gov/hsp/positiveyouthdev99/chapter2.htm.
Hawkins J.D., Brown E.C., Oesterle S., Arthur MW., Abbott R.D., Catalano, R.F. (2008). Early effects of Communities That Care on targeted risks and initiation of delinquent behavior and substance use. Journal of Adolescent Health, 43, 15-22.[pdf]
Hawkins, J. D., Oesterle, S., Brown, E. C., Arthur, M. W., Abbot, R. D., Fagan, A. A., & Catalano, R. F. (2009). Results of a type 2 translational research trial to prevent adolescent drug use and delinquency: A test of Communities That Care. Archives of Pediatric and Adolescent Medicine, 163(9), 789-798. [pdf]
Communities That Care [http://ncadi.samhsa.gov/features/ctc/resources.aspx]
Social Development Research Group [http://www.sdrg.org/]
APA (5th ed) citation for this podcast:
Singer, J. B. (Host). (2010, March 24). Communities that care: Interview with Dr. Richard Catalano [Episode 57]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2010/03/communities-that-care-interview-with.html