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Principles of Substance Abuse Prevention for Early Childhood

Chapter 3: Intervening in Early Childhood

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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,”).

Logic Model for Intervening in Early Childhood to Prevent Drug Abuse

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Text description: Logic model for intervening in early childhood to prevent drug abuse. Categories include internal and external risk and protective factors, intermediate or proximal outcomes, and long-term or distal outcomes. Internal and external risk and protective factors include responsive parenting, optimal brain development in utero through adolescence, genetic, and healthy pregnancy with reduced maternal smoking, alcohol and drug use. Intermediate or proximal outcomes include academic and other achievements, effective learning, competence, and skill development, and effective self-regulation. Long-term or distal outcomes include prevention of exposure to and opportunity to use drugs. Social and economic environment supportive of child rearing; absence of poverty and exposure to violence crosses all three categories. Arrows show connectivity between factors. Genetic, healthy pregnancy, responsive parenting, and social and economic environment supportive of child rearing lead to optimal brain development in utero through adolescence which leads to effective learning, competence and skill development. Responsive parenting also leads to academic and other achievements, which leads to effective learning, competence and skill development and prevention of exposure to and opportunity to use drugs. Effective learning, competence and skill development leads to effective self-regulation, prevention of exposure to and opportunity to use drugs, and academic and other achievements. Effective self-regulation leads to effective learning, competence, and skill development and prevention of exposure to and opportunity to use drugs. Social and economic environment supportive of child rearing leads to optimal brain development in utero through adolescence, effective self-regulation, and prevention of exposure to and opportunity to use drugs.

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.

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”)

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).

Principle 5: Early childhood interventions can positively affect children’s biological functioning.

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.

Intervening Early Can Have Long-Term Effects on a Wide Array of Behaviors
  • 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)
  • 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)
  • 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)
  • 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)
  • 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)
  • Criticism from teachers (Webster-Stratton et al., 2008)
  • Disruptive behavior (August et al., 2003)
  • School absenteeism (Snyder et al., 2010)
Service Use
  • Awareness of community services (Olds et al., 1986)
  • 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.

Principle 6: Early childhood prevention interventions should target the proximal environments of the child.

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”).

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.

Principle 7: Positively affecting a child’s behavior through early intervention can elicit positive behaviors in other people, improving the overall social environment.

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.*

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.)

* 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.
** 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.

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
Risks Intervention Strategy
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
Risks Intervention Strategy
Inappropriate expectations for children Parenting class on child development
Harsh discipline Parenting class on managing child behavior
Insecure attachment Parenting class on developing a warm, supportive relationship
Risks Intervention Strategy
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
Risks Intervention Strategy
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

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).


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.

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.

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.

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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NIDA. (2016, March 9). Principles of Substance Abuse Prevention for Early Childhood. Retrieved from https://www.drugabuse.gov/publications/principles-substance-abuse-prevention-early-childhood

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