Address Risk & Protective Factors for Individuals, Families, and Communities

Introductory Paragraph

Many factors influence a person’s chance of developing a mental health or substance use disorder (SUD). Prevention focuses on both reducing risk factors and strengthening protective factors. A key part of addressing the opioid crisis (and addiction in general) is to have a multi-faceted plan to reduce the risk factors that lead to people intentionally misusing medications or taking drugs. Prevention efforts simultaneously work to increase the protective factors that increase the likelihood of going down paths that lead to an SUD. A landmark publication by Hawkins et al. (1992) delineates this two-pronged strategy and has been built upon by prevention scientists for decades.

Key Information

Creating positive factors to help prevent drug use is essential to any prevention effort. Protective factors affect children and adults throughout every stage of their lives. Building positive factors throughout all life stages is something is extremely important. Another benefit of protective factors is their compound effect on each other. For example, the development of a good relationship may lead to interest in extracurricular activities. Positive protective factors also help prevent mental illness which in turn can help prevent SUDs. Some effective protective factors include: self-control, parental monitoring, academic competence, anti-drug use policies, and strong neighborhood attachment. Note how these span a variety of socio-ecological domains -- from individual to family to school to community. Examples of risk factors in these same domains are listed below:

• Individual -- Early Aggressive Behavior
• Family -- Lack of Parental Supervision
• School -- Drug Availability
• Community -- Poverty

SAMHSA utilizes the Strategic Prevention Framework (SPF) to help prevention professionals identify and focus upon addressing those factors that will have the greatest impact on target populations within specific communities. An assessment of risk and protective factors in the local community helps with planning the best interventions to implement. The SAMHSA risk and protective factors guide is a resource that further defines risk and protective factors. "Risk factors are characteristics at the biological, psychological, family, community, or cultural level that precede and are associated with a higher likelihood of negative outcomes. Protective factors are characteristics associated with a lower likelihood of negative outcomes or that reduce a risk factor’s impact. Protective factors may be seen as positive countering events. Some risk and protective factors are fixed: they don’t change over time. Other risk and protective factors are considered variable and can change over time."

• Variable risk factors include income level, peer group, adverse childhood experiences (ACEs), and employment status.
• Individual-level risk factors include a person’s genetic predisposition to addiction or exposure to alcohol prenatally.
• Individual-level protective factors include positive self-image, self-control, or social competence.

National Institute on Drug Abuse research has shown that the key risk periods for drug use are during major transitions in children’s lives. The first big transition for children is when they leave the security of the family and enter school. Later, when they advance from elementary school to middle school and to high school, they often experience new academic and social situations, such as learning to get along with a wider group of peers. It is at this stage of early adolescence that children are likely to encounter drugs for the first time. These are key times to have awareness and amplify protective factors for prevention.

Reducing Risk Factors

The risks are severe. Youth fentanyl overdose has reached the epidemic phase; increased purchase of illegal prescriptions laced with fentanyl has led to a 94% increase in overdose deaths in teens.

The risk of a parent’s prescription drugs getting to their children is a real concern that must be addressed by any prevention effort. The Partnership for Drug-Free Kids states “Two-thirds of teens and young adults who report abuse of prescription medicine are getting it from friends, family and acquaintances." Three steps are promoted to ensure that the young people don’t have access to any medications at home -- monitor, secure and properly dispose of unused and expired prescription and over-the-counter medicine. According to one NSDUH Annual National Report, an estimated 316,000 adolescents aged 12 to 17 misused prescription pain relievers for the first time -- that’s 900 adolescents each day. Approximately 217,000 adolescents aged 12 to 17, misused prescription stimulants for the first time – that’s 600 adolescents each day.” Understanding how to keep prescription medications safe is essential to preventing youth from being able to access them.

Prevention is a function of balancing risk factor reduction and increasing protective factors. As noted above, there is no one child who is exempt from potential drug use. Thus, by definition, all youth are at risk. So, it is essential for all parents to understand both risk and protective factor approaches to the health and wellbeing of their children. Parents who are aware of risk factors can communicate more informed education to their children and be equipped to provide early intervention, if necessary. The CDC notes the following risk factors which increase the likelihood of adolescent drug use:

• Family history of substance abuse
• Poor parental monitoring
• Permissive parenting or parent-child conflict
• Parental substance use
• Family rejection of sexual orientation or gender identity
• Association with friends or peers who use substances
• Disconnection from school
• Poor academic performance
• Childhood sexual abuse
• Mental health issues (diagnosed or undiagnosed)
• Early aggressive behaviors

It is important to understand that all of these risk factors can be addressed and intervention provided. Already occurring situations or factors have the opportunity for correction.

Enhancing Protective Factors

The simplest way to comprehend the role of protective factors is to move beyond knowing that a just-say-no approach is ineffective. The essential protective factors question is "to what should youth say yes?" The following list provides guidance on positive goals:

• Fostering good, healthy peer relationships
• Consistent, language-based discipline (as opposed to physical discipline)
• Supportive family relationships
• Extended family support
• Positive partnering between family and school
• Positive school and teacher engagement
• High but attainable academic standards
• Fostering and modeling healthy self-esteem
• Good coping and problem-solving skills, modeled and learned
• Clear expectations for behaviors
• Opportunities for meaningful engagement in school and community
• Promotion of physical and psychological safety
• Safe and healthy opportunities for autonomous behavior & decision making

Once equipped with this knowledge, parents, and guardians are at the advantage to have important conversations with their children to prevent or intervene where drug use is concerned. With every risk factor discussed above, there are protective factors that can be put into place. One of the most important is early education. Starting meaningful and open conversations about drug use and its short and long-term consequences. Beginning the conversation early and continuing with age-appropriate information provides key benefits and protective factors for the child. They are armed with the knowledge of what drugs are and the potential consequences of using them. This advanced warning prevents exposure from peer pressure. These conversations can foster an open, welcoming relationship in which youth feel safe to ask more questions, express concerns, and confide in and seek help from parents. SAMHSA points out an important reason why parents need to have conversations about drugs rather than avoid the topic: avoiding discussions about substance use can send the message to children that there isn’t any harm. Early and frequent talks set clear expectations and boundaries in a safe space.

Parent Impact and Involvement in Prevention

Parents play a vital role in preventing teen girls from unplanned pregnancies. Because teens are more likely to not notice that they are pregnant and much more likely to engage in risky behaviors such as substance use and binge drinking, parents should aim to educate their teens early. Parents can begin to talk with their children about not only the risks of substance use, but the risks of becoming pregnant, and how to prevent unwanted pregnancy. SAMHSA reports that most pregnant teens used marijuana and drank alcohol more frequently than other substances before pregnancy. Experts believe that this trend exists because teens have a misconception that there are fewer risks involved when choosing to use these substances compared to other illicit drugs. It may be beneficial to increase prevention and intervention strategies for these particular substances among teens. Public health campaigns can begin to highlight the direct and indirect consequences of use, such as criminal justice involvement, unwanted pregnancy, addiction, and greater risk of exposure to sexually transmitted diseases.

Relevant Research

NIDA -- The National Institute on Drug Abuse is the largest supporter of the world’s research on substance use and addiction. Part of the National Institutes of Health, NIDA conducts and supports biomedical research to advance the science on substance use and addiction and improve individual and public health.

SAMHSA -- A robust summary of prevention research can also be found in SAMHSA (2019) - "Substance Misuse Prevention for Young Adults."

Impactful Federal, State, and Local Policies

The National Prevention Strategy (NPS) was called for under the Affordable Care Act. It serves as a framework for the identification of policy objectives to advance prevention. The NPS was developed by the National Prevention Council, a collaborative effort by seventeen federal agencies. One component of NPS that is particularly significant is the complementarity of four strategies that address both individual and community responsibilities in promoting health and wellness:

• Healthy and Safe Community Environments
• Clinical and Community Preventive Services
• Empowered People
• Elimination of Health Disparities

The NPS is also significant in its emphasis on the integration of its seven priorities:

• Tobacco Free Living
• Preventing Drug Abuse and Excessive Alcohol Use
• Healthy Eating
• Active Living
• Injury and Violence Free Living
• Reproductive and Sexual Health
• Mental and Emotional Well-Being

Available Tools and Resources

• SAMHSA has published "A Guide to SAMHSA’s Strategic Prevention Framework" which includes information on the assessment of risk and protective factors. SAMHSA also holds an event called National Prevention Week (NPW) that aims to raise awareness about substance use and positive mental health. NPW showcases evidenced-based intervention programs, improves partnerships and collaborations with different agencies and organizations, and promotes quality prevention strategies and resources. The NPW website has webinars for various topics relating to substance use. These webinars contain valuable information about prevention and education.

• SAFE Project:
  • SAFE Choices. This SAFE Project program focuses on fostering resiliency in youth development through collaborative and diversified approaches that reduce risk of substance addiction and mental health challenges while empowering SAFE Choices in all stages of youth development.
  • Bridging Prevention and Recovery (BPR): A Community Approach to Systems Change. This SAFE Project program, offered in-person and virtually, guides community leaders through an action-oriented model to systemically integrate prevention and recovery systems to strengthen programs and improve outcomes. BPR is a 3.5 day training program that culminates with 6 technical assistance sessions tailored to each community’s unique set of needs to support implementation and sustainability of joint prevention and recovery community projects.

Protective Factors -- Approaches in Child Welfare is an issue brief produced by the Children's Bureau within the US Department of Health and Human Services

Promising Practices

Communities that Care guides communities through a five-phase change process based on "Social Development Strategy." Using prevention science as its base, CTC promotes healthy youth development, improves youth outcomes, and reduces problem behaviors. Documented outcomes include

• 25% less likely to have initiated delinquent behavior
• 32% less likely to have initiated the use of alcohol
• 33% less likely to have initiated cigarette use than control community youths

The Search Institute provides a framework for prevention that is based upon both community commitment to youth and an asset-based or positive psychology model. The identification of 40 developmental assets was based upon years of research and has provided communities with a way to index and measure change in youth behavior. The work of the Search Institute has reached over 3 million youth.

The Ohio Opioid Education Alliance is an example of implementation of approaches to address risk and protective factors.

Start Talking The state of Ohio takes a multi-faceted approach to address the current epidemic. Efforts include promoting public and professional education, increasing enforcement and interdiction efforts on our highways, and expanding treatment options and recovery supports.