“Clinical Developmental & Health Psychology – Lecture 8 (UNIVERSITY OF AMSTERDAM)”

The intervention spectrum includes promotion (1), prevention (2), treatment (3) and maintenance (4). It is used to determine what needs to be done as an intervention.

Intervention and prevention lead to positive health outcomes. However, there is not always an obvious distinction. Intervention is namely also a form of prevention (e.g. preventing the condition from getting worse). Besides that, there are also preventive interventions.

There are different types of prevention/intervention:

1. Universal prevention
   This is characterized by it targeting an entire population. There is no regard for individual risk factors. It is provided to everyone in the population (e.g. school).
2. Selective prevention
   This targets subgroups of the general population. Typically, the subgroups determined at risk for substance abuse are included (e.g. children of substance abusing parents). The recruitment is based on risk profiles.
3. Indicated prevention
   This includes identifying individuals who are experiencing early signs of substance abuse. There is no clinical diagnosis but risk factors are identified. It can consist of special programmes (e.g. substance abuse programme for high school students experiencing a number of problematic behaviour).
4. Treatment
   This includes the treatment for people with a substance abuse disorder. It includes a diagnosis and the treatment can be group-based or individual.

Single-component interventions are delivered in one setting. It has one target and it is a stand-alone initiative. It can also focus on one component in a brief intervention (e.g. only focus on social norms). Multi-component interventions are delivered in more than one setting. It focuses on more components in brief interventions (e.g. social norms, money spent and protective behavioural strategies).

A multi-component programme often is a strategic framework with a theoretical basis for action. It consists of a programme of coordinated projects addressing the problem based on an integrative programme design where singular interventions run in combination with each other and are sequenced together over time. It includes identification (1), mobilization (2) and coordination (3) of appropriate agencies, stakeholders and local communities. There is an emphasis on modifying cultures, policies, structures and systems.

Interventions are based on theoretical frameworks. The target of interventions (e.g. communication; self-control) depends on the group that is targeted.

During adolescence, there is distancing from parents (1), intensifying of peer contacts (2) and experimentation with adult-like behaviour (3). After an anti-alcohol use campaign in the Netherlands, strict alcohol-specific parenting practices decreased alcohol use among adolescents. This is indicative of a social-cultural change regarding alcohol use. The parents appear to be important for adolescent alcohol use.

A combined intervention (i.e. aimed at both parents and the adolescents) appears to be most effective in battling substance use (e.g. alcohol) in adolescence. This effect is mediated by attitudes about alcohol (1), changes in rules about alcohol (2), self-control (3), and rules about alcohol (4). However, there are no changes in the adolescent attitude towards alcohol. Self-control appears to be the most important aspect of tackling substance use in adolescents. Alcohol use can be postponed by targeting adolescents and parents. There is a causal link between alcohol use and adolescents’ self-control and strict parental rule-setting.

Currently, treatment tends to be expensive (1), it is rarely tailored to adolescents (2) and are difficult to consistently access for patients (3). Technology-based treatment could help with this.

Technology-based universal intervention is typically provided in three settings.

1. Primary care setting
   In a primary care setting, the technology-based interventions appear to result in lower cumulative proportion of cannabis use compared to an educational brochure.
2. School setting
   
   1. CLIMATE
      This intervention is based on social influence research and includes providing information, roleplaying and discussion. It is more effective than standard health class curricula.
   2. HeadOn
      This intervention is designed for youth between grade 6 and 8 and consists of interactive, simulated scenarios that require youth to engage in substance-related decision making.
3. Home setting
   During these interventions, parents can interact with the child during the intervention and this offers opportunities to reinforce new behaviours and beliefs to foster healthy relationships. It leads to a better self-efficacy in youth and less substance use.

Technology-based selective prevention is typically provided in two settings.

1. Medical setting
   1. Primary care
      Here, at-risk adolescents fill in a questionnaire to calculate a risk score for the physician. This typically results in better outcomes.
   2. Emergency room
      In this setting, people typically receive screening which opens the possibility for counselling. This improves perceptions of substance use.
2. University setting
   This consists of providing counselling after a substance-use related incident and preventive interventions to a large group of students. It makes use of personalized normative feedback.

Personalized normative feedback changes student’s perceptions of norms and their alcohol use by providing corrective information about normative drinking among peers. This allows adolescents to compare their drinking behaviour with peers.

There are several technology-based treatments:

1. Therapeutic Education System (TES)
   This is a web-based intervention designed to help individuals with addiction develop skills emphasized in cognitive-behavioural therapy and relapse prevention training.
2. Step Up
   This is a web-based intervention designed to help participants develop assertiveness and communication skills.
3. Identifying Therapeutic Opportunities: Ecological Momentary Assessment
   This involves repeated sampling of current behaviours and experiences in real-time in the participants’ natural environment. This leads to an accurate profile of the temporal relationship between behaviours and outcomes. It allows us to identify when, where and why youth are most vulnerable.
4. Educating and Supporting Inquisitive Youth in Recovery
   This helps youth maintain sobriety after treatment and consists of sending text messages tailored to the severity of problems experienced.
5. Momentary Self-Monitoring and Feedback Motivational Enhancement
   This intervention consists of a meeting with a counsellor to discuss triggers and then the youth report the triggers, cravings and use using their phone and they receive text messages to help them cope with the identified triggers.

Advantages of technology-based interventions are that it can target a large group (1), it can be tailored to different sub-groups (2), it can facilitate rapid dissemination to large groups (3), it allows for permanent access to support (4), it can be used to respond quickly and effectively to provide a scalable response (5), it can be used as a stand-alone or add-on to face-to-face therapy (6) and it is cost-effective (7).

The dual-process models state that behaviour is determined by an interplay between fast associative impulsive processes and slower reflective processes. This means that behaviour can depend on strength of specific associations (1), conscious beliefs (2), strength of executive control processes at the time (3) and motivation to make adjustments (4).

The automatic processes are motivational systems (e.g. seeing a cue and wanting to use substances). The conscious processes include conscious beliefs. These two systems are intertwined. The combination of strong impulsive and weak reflective processes result in susceptibility to cues triggering the addictive behaviour. This, in turn, leads to difficulties in inhibiting the tendency to engage in the addictive behaviour. The implicit processes may be stronger among adolescents because impulse control processes have not been fully developed while emotional and reward-seeking processes are more active.

The incentive sensitization theory states that substance use behaviours can be triggered automatically by seeing a cue (e.g. ashtray for smoking). These cues lead to an attentional and motivational bias. In addition to that, there are implicit associations. These things influence one’s spontaneous, automatic response to a substance use-related cue. The measuring tools for these biases could be used to change the bias towards something positive or neutral (e.g. retraining approach bias).

Adolescents who were impulsive and received AAT (i.e. approach-avoidance task) training had a larger chance of abstinence of substance use. There generally is less smoking after participating in interventions. This is not always attributable to cognitive bias modification. The impulsive smokers benefit more from interventions aimed at automatic processes (e.g. mostly young people). The challenge of intervention for smoking cessation is dealing with dropouts and motivation of the participants. The approach bias for smoking was decreased for people who already had an approach bias and this effect was moderated by pre-treatment strength of approach bias.

Substances are often embedded in social context (e.g. drinking with friends).  This means that substance use is motivated by social contexts and this also influences the readiness to change.

The motivation could be targeted in interventions using gamification (1), motivational interviewing (2) and the for-what intervention (3). Motivational interviewing is not always effective for youth and the for-what intervention is aimed at parents. One of the goals is to change motivation from extrinsic to intrinsic as this tends to be more effective in eliciting long-lasting change. This requires youth involvement.

Status (1), belongingness (2) and feeling respected by adults and peers (3) is important for adolescents. This should be incorporated into treatment interventions. This means that when targeting an intervention at adolescents, it is important to not just copy an intervention and use it on adolescents. The intervention needs to be tailored to adolescents.

It is important to take into account what is important in different phases of life (1), the developmental tasks (2), the contexts (3) and age-related patterns of competence (4) when it comes to evaluating substance use.