8

Investing in Prevention

Putting a value on the impact of violence, while often an incomplete picture, provides evidence for investing in preventive interventions. Both enumerated and estimated costs—economic and social—indicate an enormous burden on public health. In particular, violence at specific points along the life span can have a greater impact. Also, addressing violence after it occurs, in addition to preventing the recurrence of violence, can be costly.

Thus, investing in early prevention can have significant financial benefit. It can prevent violence before it begins, or it can prevent the development of longer-term outcomes of violence.

The first paper in this section examines the value of prevention, by exploring the costs of violence and the costs of intervention. It also explores different methods of assessing value to highlight the importance of a number of perspectives on prevention.

The second paper is an example of a community-based preventive intervention that builds resiliency and prosocial behavior in individuals and the community as a whole. It also demonstrates the cost-effectiveness of prevention.

THE VALUE OF PREVENTION

Rachel A. Davis, M.S.W.
Prevention Institute

Prevention has tremendous value, and there are many ways to think about its value in the context of preventing violence. Prevention is a systematic process that reduces the frequency or severity of illness or injury,



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8 Investing in Prevention Putting a value on the impact of violence, while often an incomplete picture, provides evidence for investing in preventive interventions. Both enumerated and estimated costs—economic and social—indicate an enor- mous burden on public health. In particular, violence at specific points along the life span can have a greater impact. Also, addressing violence after it occurs, in addition to preventing the recurrence of violence, can be costly. Thus, investing in early prevention can have significant financial ben- efit. It can prevent violence before it begins, or it can prevent the develop- ment of longer-term outcomes of violence. The first paper in this section examines the value of prevention, by ex- ploring the costs of violence and the costs of intervention. It also explores different methods of assessing value to highlight the importance of a num- ber of perspectives on prevention. The second paper is an example of a community-based preventive interven- tion that builds resiliency and prosocial behavior in individuals and the com- munity as a whole. It also demonstrates the cost-effectiveness of prevention. THE VALUE OF PREVENTION Rachel A. Davis, M.S.W. Prevention Institute Prevention has tremendous value, and there are many ways to think about its value in the context of preventing violence. Prevention is a sys- tematic process that reduces the frequency or severity of illness or injury, 113

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114 SOCIAL AND ECONOMIC COSTS OF VIOLENCE and primary prevention promotes healthy environments and behaviors to head off problems before the onset of symptoms. Ten ways of thinking about the value of prevention are the following: 1. Direct costs of not preventing violence 2. Indirect costs of not preventing violence 3. Savings due to prevention 4. Advantages of a prevention approach 5. Partnerships and multisector collaboration 6. A good solution solves multiple problems 7. Prevention works 8. Multiplier effect 9. Efficient government 10. Prevention reduces suffering and saves lives Direct Costs of Not Preventing Violence One way to appreciate the value of preventing violence is to understand the costs of violence. A single violent incident is far more expensive than many realize. For example: •  Every fatal assault costs $4,906 on average, with another $1.3 mil- lion in lost productivity (Corso et al., 2007). •  Every nonfatal assault costs approximately $1,000 on average, with $2,822 in lost productivity (Corso et al., 2007). •  The economic cost of violent deaths was $47.2 billion in 2005. This includes medical treatment and lost future wages (CDC, 2011). •  The cost of sexual and domestic violence exceeded $5.8 billion— $319 million for rape, $4.2 billion for physical assault, and $1.75 billion in lost earnings and productivity (National Center for Injury Prevention and Control, 2003). On top of the cost to the government and the taxpayer for each indi- vidual act of violence, add the expense of long-term incarceration for perpetrators: •  The American Correctional Association estimates that it costs states an average of $240.99 per day—around $88,000 a year—for every young person housed in a juvenile facility in 2008 (Justice Policy Institute, 2009). •  States spent approximately $5.7 billion to imprison 64,558 young people across the United States in 2007 (Puzzanchera and Sickmund, 2008).

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115 INVESTING IN PREVENTION These costs are incurred for every incident of violence that is not pre- vented. More than 650,000 young people ages 10 to 24 are treated every year in emergency departments for injuries sustained from violence, and homicide is the second leading cause of death among youth between the ages of 10 and 24 (CDC, 2010). When that many young people regularly experi- ence violence in their neighborhood or at home, the cost can only increase. The Advancement Project in Los Angeles attempted to account for these costs in one locale, and its analysis demonstrated that gang violence in the City of Los Angeles cost the city, the County of Los Angeles, and the State of California $1.145 billion every year in criminal justice costs alone (Vera Institute of Justice, 2011). This astronomical amount, $1.145 billion, covers only the criminal justice costs of arresting and processing gang members in a single city. Imagine how high this amount would be if the analysis included other kinds of violence, factored in costs in addition to criminal justice, and covered cities across the United States, not just Los Angeles. Multiply $1.145 billion by those factors, and this will provide an approximate idea of how expensive violence can be. Violence is enormously costly in services after the fact, including medi- cal care, criminal justice, social services, and law enforcement. Treating gang members’ gunshot wounds in the City of Los Angeles (LA), for example, costs the government approximately $45,296,446 annually in medical care (Vera Institute of Justice, 2011). Altogether, victims of LA gang violence pay more than $1 billion in out-of-pocket and quality-of-life costs (Vera Institute of Justice, 2011). Interventions at the first sign of trouble are unusual, so it is not atypi- cal for one individual to have many interactions with the criminal justice system over decades. A child whose first memories are of violence is far more likely to perpetuate violence throughout life. Frequently when a child victim of violence is not cared for at the first sign of trouble, that child grows up to be an adult victim of violence and is repeatedly suspected and arrested for violent crime. Every subsequent encounter that one child has with the criminal justice, social services, and medical systems as he grows up makes violence more and more expensive for communities, taxpayers, and the larger society. These expenses pile up when violence is not prevented, and “economic costs provide, at best, an incomplete measure of the toll of violence,” ac- cording to the Centers for Disease Control and Prevention (CDC, 2007). This suggests that the true cost of violence is actually far greater than that captured by the direct costs. Indirect Costs of Not Preventing Violence Another way to think about the value of prevention is to consider the indirect costs when violence is not prevented. Violence reduces tourism and

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116 SOCIAL AND ECONOMIC COSTS OF VIOLENCE neighborhood business activity, resulting in the loss of private revenues and public tax dollars. It also undermines health and can exacerbate and contribute to the onset of chronic conditions and mental health problems. Mental Health Those who fear violence and those who experience violence as vic- tims, perpetrators, and witnesses also suffer emotional and mental health consequences. These enduring negative effects can span a lifetime, require extensive treatment, and in turn affect physical health. Research has identi- fied the following mental health conditions as significantly more common among those exposed to violence, either directly or indirectly: •  Depression and risk for suicide (Campbell, 2002; Chilton and Booth, 2007; Clark et al., 2008; Curry et al., 2008; Kilpatrick et al., 2003; Latkin and Curry, 2003; Paolucci et al., 2001; Pastore et al., 1996; Veenema, 2001) •  Posttraumatic stress disorder (PTSD) (Kilpatrick et al., 2003; Paolucci et al., 2001; Veenema, 2001) •  Aggressive and/or violent behavior disorders (Campbell, 2002; Fowler et al., 2009; Paolucci et al., 2001; Veenema, 2001) Youth with past exposure to interpersonal violence have significantly higher risk for PTSD, major depressive episodes, and substance abuse and dependence. In many U.S. neighborhoods, violence is so traumatiz- ing that 77 percent of children exposed to a school shooting and 35 percent of urban youth exposed to community violence develop PTSD, far higher than the rate for soldiers deployed to combat areas in the last 6 years (20 percent) (Kilpatrick et al., 2003; National Center for PTSD, 2007, 2009). Chronic Diseases Violence can also affect changes that undermine our overall health. Violence is associated with a broad range of chronic illnesses, such as •  Asthma (Apter et al., 2010; Fujiwara, 2008; Sternthal et al., 2010; Suglia et al., 2009; Wright and Steinbach, 2001; Wright et al., 2004); •  Heart disease and hypertension (Carver et al., 2008; Felitti et al., 1998); •  Ulcers and gastrointestinal disease (Prevention Institute, 2011b); •  Diabetes (Carver et al., 2008; Felitti et al., 1998);

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117 INVESTING IN PREVENTION •  Neurological and musculoskeletal diseases (Prevention Institute, 2011b); and •  Lung disease (Carver et al., 2008; Felitti et al., 1998). Violence and fear of violence are also significant barriers to healthy eating and active living. People are less likely to use local parks or walk to school when they do not feel safe in their neighborhood, for example, and violence reduces investments in communities—for example, by grocery stores (Bennett et al., 2007; Shaffer, 2002; Zenk et al., 2005). This means that safety concerns cause people to exercise less and spend less time out- doors (Burdette et al., 2006; Carver et al., 2008; CDC, 1999; Eyler et al., 2003; Gomez et al., 2004; Harrison et al., 2007; Johnson et al., 2009; Loukaitou-Sideris, 2006; Lumeng et al., 2006; Molnar et al., 2004; Sallis et al., 2008; Weir et al., 2006; Williamson et al., 2002; Wilson et al., 2004; Yancey and Kumanvika, 2007). Violence also alters people’s purchasing patterns and limits access to healthy food (Bennett et al., 2007; Neckerman et al., 2009; Odoms-Young et al., 2009; Vasquez et al., 2007; Zenk et al., 2005). Experiencing and witnessing violence cause trauma and can decrease motivation and capabil- ity to eat healthfully and be active (Alvarez et al., 2007; Boynton-Jarrett et al., 2010; Chilton and Booth, 2007; Felitti et al., 1998; Frayne et al., 2003; Greenfield and Marks, 2009; Vest and Valadez, 2005). Violence and fear of violence diminish community cohesion, which reduces support for healthy eating and active living (Cradock et al., 2009; Harrison et al., 2007; Johnson et al., 2009; Odoms-Young et al., 2009; Rohrer et al., 2004; Vest and Valadez, 2005). Chronic illness resulting from unhealthy eating and ac- tivity account for a growing percentage of escalating costs in the healthcare system (Hogan et al., 2003; Huang et al., 2009; Prevention Institute, 2010; Prevention Institute et al., 2007; Thorpe et al., 2004). Savings Due to Prevention Given the expense of violence is in terms of dollars and community health, there is increased recognition that prevention is a smart investment. Prevention preempts both the direct and the indirect costs of violence and translates into huge savings. Direct Savings By preventing violence before it happens, investments are made now rather than paying more later to cover the outsized after-the-fact costs of violence. Investing in programs such as high-quality preschool, for exam- ple, can yield immense savings. A cost-benefit analysis of the High Scope

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118 SOCIAL AND ECONOMIC COSTS OF VIOLENCE Perry Preschool Program showed a return of $16.14 per dollar invested (Schweinhart et al., 2005). By age 40, the African-American children who participated in the preschool program as 3- and 4-year-olds had significantly fewer arrests for violent crime, drug felonies, and violent misdemeanors and served fewer months in prison compared to nonparticipants (Schweinhart et al., 2005). Every child who grows up safe and healthy means one more person who does not encounter these institutions and systems. Indirect Savings Reducing violence is an effective way to stimulate economic development in affected communities (Bollinger and Ihlanfeldt, 2003; Lehrer, 2000), and preventing violence yields indirect savings by promoting health in the long run. Preventing violence would reduce demand for healthcare services by lower- ing these incidence and prevalence rates, which would void the associated healthcare costs for thousands of people who would otherwise have fallen ill. Advantages of a Prevention Approach Criminal justice has historically received most attention when it comes to violence, but effectively addressing this problem requires an approach that emphasizes prevention and also includes intervention, enforcement, and successful reentry. This prevention-oriented approach provides a meth- odology that extends beyond programs and has the potential to change systems and shape social norms. This additional capacity is another way to weigh the value of prevention. According to an Institute of Medicine (IOM, 2000) report on behavior change, “It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environ- ment conspire against such change.” Rather than intervening after people are injured and working with one individual at a time, primary prevention means changing the larger environment before problems arise. A complex issue such as violence requires a multifaceted, comprehen- sive solution. Rather than only working with one person at a time to treat the effects of violence or to increase individual knowledge and skills, pre- vention also addresses the underlying causes of violence at the community and societal levels. Although single programs have been shown to reduce violence, there is a continuous need for comprehensive approaches, for ef- fectiveness and to ensure sustainability. Partnerships and Multisector Collaboration No sector alone can prevent violence. Cities need integrated strategic plans and coordinated efforts across multiple sectors such as education;

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119 INVESTING IN PREVENTION health and human services, including public health, substance abuse and mental health, and children and families; criminal justice; early childhood development; and labor. For example, the UNITY Assessment found that cities with more multijurisdictional coordination and communication have lower rates of violence (Weiss and Southern California Injury Prevention Research Center, 2008). Coming together and owning the solutions across multiple sectors are key, and prevention informs and facilitates this process. To effectively ad- dress violence, multiple sectors must be at the table to develop and imple- ment a comprehensive solution. Another way to understand the value of prevention is to appreciate how it relies on inclusive processes and creates space for all these partners to dialogue and collaborate, as well as clarifying the roles of multiple sectors, such as addressing the complex array of risk and resilience factors. Approaching violence from only a criminal justice perspective limits the types of partners involved and narrows the scope of possible solutions, whereas focusing on prevention brings multiple partners to the table. A Good Solution Solves Multiple Problems Addressing the risk and resilience factors of violence through preven- tion reduces the likelihood of other poor health and behavior outcomes, such as teen pregnancy, substance abuse, mental health problems, and school failure (Felitti, 2002; Shonkoff et al., 2009). Preventing violence is valuable because it addresses risk factors that overlap with other poor health and behavior outcomes. Efforts to prevent violence simultaneously prevent these other problems as well. Boosting the resilience factors that make violence less likely also protects a community against these other problems. Reducing violence increases the efficacy of other health initiatives. Poli- cies that support communities to effectively prevent violence will improve health—for example, by improving access to healthy food and safe places to be active (Odoms-Young et al., 2009; Wilson et al., 2004) and enabling economic development in underdeveloped areas. Prevention Works Prevention is valuable because it is effective. There is a growing evi- dence base, grounded in research and community practice, confirming that violence is preventable. Universal school-based programs can reduce vio- lence by 15 percent in as little as 6 months (Hahn et al., 2007), for example, and street outreach and interruption strategies reduce shootings and killings by 40 to 70 percent (Skogan et al., 2008).

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120 SOCIAL AND ECONOMIC COSTS OF VIOLENCE Early results from the Blueprint for Action in Minneapolis indicate that it is possible to reduce the likelihood of violence. The Minneapolis City Council unanimously passed a resolution that declared youth vio- lence a public health issue and mandated a multifaceted long-term solu- tion to address youth violence called the Blueprint for Action. As a result, homicides of youth decreased by 77 percent between 2006 and 2009 (City of Minneapolis, 2011). The number of youth suspects dropped by 60 percent from 2006 to 2010, and the number of youth arrested for violent crime is down by one-third of what it was 4 years ago (Rybak, 2011). In addition, high school graduation rates at Minneapolis public schools increased to nearly three out of four in 2010, up from only 55 percent in 2005 (City of Minneapolis, 2011). As a result of this remarkable early success, the Blueprint for Action expanded its programs from the 4 initial neighborhoods to 22 neighborhoods in 2009 (Prevention Institute, 2011). Multiplier Effect Another way of thinking about the value of prevention is in its myriad long-term benefits. The benefits of preventing violence are multiplied be- cause preventing violence generates a ripple effect and a slew of positive outcomes. Preventing violence can initiate a cascade of improved health and savings. Investing in prevention reduces the prevalence and severity of violence and related injury and disability, as well as of associated condi- tions, such as chronic disease, mental illness, and poor learning. This means reduced healthcare expenditures related to violence and associated health conditions. People who would otherwise be hospitalized, sick, injured, or disabled due to violence or associated health conditions can continue to work and study, which yields savings in terms of increased attendance and productivity. Efficient Government Prevention is valuable because it promotes efficient government when embedded in existing efforts, policies, and practices. It can contribute to efficiencies within local, state, and federal agencies; reduce duplication of efforts; create opportunities to leverage existing resources; and allow for the alignment of resources. Partners can share information and resources and minimize “reinventing the wheel.” Further, embedding efforts to pre- vent violence within multiple agencies and sectors (e.g., housing, economic development, public works, education) can leverage existing resources for maximum benefit.

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121 INVESTING IN PREVENTION Prevention Reduces Suffering and Saves Lives The value of prevention can also be measured in the ways it fosters well-being and promotes healthy communities. Prevention yields all of these savings and benefits, and it also spares victims, perpetrators, and their loved ones the heartache, grief, and pain that violence causes. In addition to monetary expenses, violence incurs costs that cannot easily be calculated, such as the potential of young lives lost too soon, reduced quality of life, and neighborhoods in which people neither trust each other nor venture outside due to fear. Summary These are some ways to appreciate the value of prevention. Violence is extremely costly, not just in terms of lives, but also in the form of crimi- nal justice expenses, medical costs, lost productivity, and disinvestment. Further, violence and trauma are linked to the onset of chronic diseases and mental health problems, and caring for chronic diseases represents the most costly and fastest-growing portion of healthcare costs for individuals, businesses, and government. Yet violence is preventable, and prevention is of great value by any criteria. For many young people, violence is the most pervasive aspect of grow- ing up in their neighborhood. Young people need connection, identity, opportunity, and hope. When these things are not provided, young people turn elsewhere for them, and too often they turn to gangs and to violence. We do know how to provide these things in communities, and we need to make this a priority. Prevention values lives. COMMUNITIES THAT CARE: BRIDGING SCIENCE AND COMMUNITY PRACTICE TO PREVENT ADOLESCENT HEALTH AND BEHAVIOR PROBLEMS INCLUDING VIOLENCE J. David Hawkins, Ph.D., Richard F. Catalano, Ph.D., and Margaret R. Kuklinski, Ph.D. Social Development Research Group, University of Washington School of Social Work Prevention science emerged in the late twentieth century as a discipline built on the integration of life course development research, community epidemiology, and preventive intervention trials. Advances in prevention science have important implications for the healthy development of adoles- cences. Researchers have identified longitudinal predictors, such as family conflict or early academic failure, that increase the likelihood that young

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122 SOCIAL AND ECONOMIC COSTS OF VIOLENCE people will engage in problem behaviors associated with significant morbid- ity and, in some cases, mortality. Other predictors, such as strong bonds to positive adults or the development of specific competencies, are protec- tive, associated with reducing problem behaviors and increasing favorable outcomes such as academic success, even in the presence of risk. As shown in Table 8-1, many of these risk and protective factors are common to mul- tiple adolescent problem behaviors, which suggests that improvements in risk and protection can affect a broad set of outcomes simultaneously. Re- searchers have used this research base on risk and protection to design and evaluate prevention programs in controlled trials and have found a number of them effective in reducing risk factors, enhancing protective factors, and reducing problem behaviors. Over time, an evidence base of “what works” has been established, and several lists of tested and effective programs have been made available to the public. Implementing scientifically tested and effective prevention programs to address youth risk and protective factors is a viable strategy for reducing prevalent and costly problem behaviors, including adolescent substance use and delinquency. In spite of these advances, scientifically based approaches have not been widely used in schools and communities, and effective prevention systems have not been broadly established. Reasons include a lack of knowledge about scientifically proven prevention programs, difficulty marshaling re- sources for science-based prevention and health promotion efforts, and failure to implement proven programs with fidelity. The Communities That Care (CTC) prevention system, which mobilizes community stakeholders to collaborate on the development and implementation of a science-based community prevention system, was developed to address these concerns (Hawkins and Catalano, 1992). CTC has been developed over more than 20 years and has improved through community and research input. Here, we describe the CTC approach to prevention, steps involved in its imple- mentation, major findings from a randomized controlled trial, and its dis- semination (Hawkins and Catalano, 1992). Implementing Communities That Care A major challenge for prevention scientists committed to applying re- search in the “real world” is to increase the use of tested and effective preven- tion policies and programs while recognizing that communities differ from one another and need to decide locally what policies and programs to use. Hawkins and Catalano developed CTC, a coalition-based system for pre- venting a wide range of adolescent problem behaviors, including substance use and delinquency, with these needs in mind. CTC is guided by the Social Development Model, which holds that in order to develop healthy, positive behaviors, young people must be

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123 INVESTING IN PREVENTION TABLE 8-1 Many Youth Problem Behaviors Share Underlying Risks ety Anxi t e u Abus n and op-O ncy cy a Pregn quen ol Dr tance essio ce n Delin Depr Scho Viole Subs Teen RISK FACTORS Community Availability of drugs ✓ ✓ Availability of firearms ✓ ✓ Community laws and norms ✓ ✓ ✓ favorable to drug use, firearms, and crime Media portrayals of violence ✓ ✓ Media portrayals of substance abuse ✓ Transitions and mobility ✓ ✓ ✓ ✓ Low neighborhood attachment and ✓ ✓ ✓ community disorganization Extreme economic deprivation ✓ ✓ ✓ ✓ ✓ School Academic failure beginning in late ✓ ✓ ✓ ✓ ✓ ✓ elementary school Lack of commitment to school ✓ ✓ ✓ ✓ ✓ Family Family history of problem behavior ✓ ✓ ✓ ✓ ✓ ✓ Family management problems ✓ ✓ ✓ ✓ ✓ ✓ Family conflict ✓ ✓ ✓ ✓ ✓ ✓ Favorable parental attitudes and ✓ ✓ ✓ involvement in problem behavior Peer and Individual Early, persistent antisocial behavior ✓ ✓ ✓ ✓ ✓ ✓ Rebelliousness ✓ ✓ ✓ Friends engage in problem behavior ✓ ✓ ✓ ✓ ✓ Gang involvement ✓ ✓ ✓ Favorable attitudes toward problem ✓ ✓ ✓ ✓ behavior Early initiation of problem behavior ✓ ✓ ✓ ✓ ✓ Constitutional factors ✓ ✓ ✓ ✓

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Total School-Based Programs After-School Programs Parent-Training Programs 130 100 80 60 40 20 Percentage Actually Delivered 0 4 n* g e n g T L e rt rs h y* ts es rs ills io in -1 se io n t ar le te ut or ic el t rin n te u TA AR A C Sk s o C is 10 at ce ai ua ho en Yo n Ab s ut s Si ct M W al TO C Tr SM es ho d T e ev g ar ar g ig y d ol ilie ily Ev W oj lls ue ru Pr a d in St i l Le t /B s oo l D Pr g nt am St am d er Sk nt rA en Va G Al o F F in re th an fo re N ly g fe l o pm ng n e i s Pa Li o Pa ills Br ni id Bu at rd el e u p a g s Sk ci G th ev w t Bi ti g eu o D es ar lw en tT u m r P O Q ra ec St g s oj n’ ro Pr o P Li Percentage of Required Material or Components Actually Delivered Percentage of Required Number, Length, and Frequency of Session Actually Delivered FIGURE 8-1 Adherence to prevention program design specifications in Community Youth Development Study communities averaged across all intervention years. NOTE: * No session fidelity forms submitted. Figure 8-1.eps R02080 sized for landscape above, portrait below

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131 INVESTING IN PREVENTION TABLE 8-2 Risk Factors Targeted by Community Youth Development Study Communities Domain and Risk Factor No. of Communities Community Laws and norms favorable to drug use 1 School Low commitment to school 9 Academic failure 5 Family Family conflict 3 Poor family management 4 Parental attitudes favorable to problem behavior 1 Peer Antisocial friends 7 Peer rewards for antisocial behavior 2 Individual Attitudes favorable to antisocial behavior 3 Rebelliousness 3 Low perceived risk of drug use 2 Effects on Risk Factor Exposure The longitudinal panel youth in CTC and control communities re- ported similar levels of targeted risk in grade 5, when the intervention be- gan (Hawkins et al., 2008a), but targeted risk exposure grew more slowly for adolescents in CTC communities between grades 5 and 10 (Hawkins et al., in review). Significantly lower levels of targeted risk were first reported by CTC panel youth 1.67 years into the intervention in grade 7 and have continued to be reported by CTC panel youth through grade 10. Preventive Effects on the Initiation of Delinquency and Substance Use Panel youth from CTC and control communities also reported similar levels of delinquency, alcohol use, and cigarette smoking at grade 5 base- line. However, between grades 5 and 10, CTC had significant effects on the initiation of these behaviors by young people. Significant differences in the initiation of delinquency were first observed in the spring of grade 7. Panel youth from CTC communities were 25 percent less likely than panel youth from control communities to initiate delinquent behavior, and they remained so in grade 8. Significantly lower delinquency initiation rates were sustained through grade 10 (Hawkins et al., in review), when panel youth

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132 SOCIAL AND ECONOMIC COSTS OF VIOLENCE from CTC communities were 17 percent less likely to initiate delinquency than panel youth from control communities. Preventive effects on alcohol use and cigarette use were first observed in the spring of grade 8, 2.67 years after intervention programs were imple- mented. Grade 8 youth from CTC communities were 32 percent less likely to initiate alcohol use and 33 percent less likely to initiate cigarette smok- ing than grade 8 youth from control communities (Hawkins et al., 2009). Preventive effects were again sustained through grade 10 (Hawkins et al., in review), when CTC panel youth were 29 percent less likely to initiate alcohol use and 28 percent less likely to initiate cigarette smoking than panel youth from control communities. Differences in the initiation of delinquency, alcohol use, and cigarette smoking from grades 5 through 10 led to cumulatively lower rates of initia- tion over time (see Figure 8-2): 62 percent of 10th-grade youth in the panel from CTC communities had engaged in delinquent behavior compared with 70 percent of 10th-grade youth in the panel from control communities; 67 percent versus 75 percent had initiated alcohol use; and 44 percent versus 52 percent had smoked cigarettes. Reductions in the Prevalence of Delinquency, Violence, and Substance Use CTC also significantly reduced the prevalence of youth problem behav- iors in grade 8 and grade 10. In grade 8, the prevalence of alcohol use in the past month, binge drinking (five or more drinks in a row) in the past 2 weeks, and the variety of delinquent behaviors committed in the past year were all significantly lower in CTC panel youth compared to control com- munity panel youth (Hawkins et al., 2009). A subset of the delinquency items was used to create a measure of violent behavior in the fifth grade (attacking someone with intent to harm; range 0 to 1) and the 10th grade (attacking someone with intent to harm, carrying a gun to school, beating somebody up; range from 0 to 3). The CYDS found significant effects of CTC in reducing the prevalence of delinquent behavior and violence in the past year in the spring of grade 10 (Hawkins et al., in review). Tenth-grade students in CTC communities had 17 percent lower odds of reporting any delinquent behavior in the past year (t (9) 5 22.33; p 5 .04; AOR [adjusted odds ratio] 5 .83) and 25 percent lower odds of reporting any violent behavior in the past year (t (9) 5 22.51; p 5 .03; AOR 5 .75) compared to students in control communities. CTC Is a Cost-Beneficial Intervention A cost-benefit analysis was undertaken to determine whether CTC is a sound investment of public dollars, based on significant preventive effects

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The percentage of youth ini a ng delinquency, alcohol use, and cigare e smoking from Grade 5 to Grade 10 is significantly lower in youth exposed to CTC. Delinquency Cigarette Smoking Alcohol Use 80 60 75% 80 52% 67% 70% 65% 59% 44% 57% 60 37% 67% 60 62% 47% 61% 40 48% 57% 44% 39% 38% 53% 26% 36% 49% 40 40 32% 44% 23% 41% 18% 23% 33% 24% 20 30% 9% 20 17% 20 20% 20% 7% 0 Cumulative Initiation 0 Cumulative Initiation 0 Cumulative Initiation Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 CTC Control FIGURE 8-2 Communities That Care (CTC) leads to significant reductions in the cumulative initiation in delinquency and substance abuse. NOTE: The percentage of youth initiating delinquency, alcohol use, and cigarette smoking from grade 5 to grade 10 is significantly lower in youth exposed to CTC. Figure 8-2.eps R02080 sized for landscape above, portrait below 133

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134 SOCIAL AND ECONOMIC COSTS OF VIOLENCE on cigarette smoking and delinquency initiation found in grade 8 (Kuklinski et al., in review). CTC’s long-term financial benefits from reducing initiation were compared to a very conservative CTC implementation cost of $991 per youth over 5 years. CTC was estimated to lead to $5,250 in benefits per youth, including $812 from the prevention of cigarette smoking and $4,438 from the prevention of delinquency. The benefit-cost ratio indicates a return of $5.30 per $1.00 invested, evidence that CTC is a cost-beneficial investment (Kuklinski et al., in review). CTC is currently being implemented in more than 500 communities across the United States and in countries including Australia, Canada, Germany, the Netherlands, and the United Kingdom. Dissemination of CTC All manuals and materials needed to implement CTC have been placed in the public domain by the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services and can be found at http://www.communitiesthatcare.net. In addition, it is clear from the Community Youth Development Study that high-quality training and technical assistance are important to ensuring successful implementa- tion of CTC with fidelity. CTC Guiding Principles •  Increase the use of tested and effective prevention policies and pro- grams, while recognizing that communities are different and need to decide locally what policies and programs to use. •  Identify  and  prioritize  locally  specific  elevated  risk  factors,  de- pressed protective factors, and youth problem behaviors. •  Match tested, effective prevention programs and policies to priori- ties, and implement them with fidelity. •  Measure progress periodically, and make any needed adjustments. Key Youth Outcomes A randomized controlled trial of CTC showed that grade 8 youth ex- posed to CTC fared significantly better than youth not exposed to CTC: •  Risk  factors  targeted  for  intervention  increased  less  rapidly  from  grades 5 to 8. •  CTC youth were 33 percent less likely to start smoking cigarettes,  32 percent less likely to start drinking, and 25 percent less likely to start engaging in delinquent behavior.

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135 INVESTING IN PREVENTION •  The intervention was found to be cost-effective returning $5.30 for  every dollar invested. •  These improvements have been sustained through grade 10, 1 year  after study support to communities ended. •  Effects  on  the  prevalence  of  substance  use  and  delinquency  were  generally universal, applying equally to girls and boys as well as youth who differed in risk. REFERENCES Alvarez, J., J. Pavao, N. Baumrind, and R. Kimerling. 2007. The relationship between child abuse and adult obesity among California women. American Journal of Preventive Medicine 33(1):28-33. Apter, A. J., L. A. Garcia, R. C. Boyd, X. M. Wang, D. K. Bogen, and T. Ten Have. 2010. Exposure to community violence is associated with asthma hospitalizations and emer- gency department visits. Journal of Allergy and Clinical Immunology 126(3):552-557. Arthur, M. W., J. S. Briney, J. D. Hawkins, R. D. Abbott, B. L. Brooke-Weiss, and R. F. Catalano. 2007. Measuring risk and protection in communities using the Communities That Care youth survey. Evaluation and Program Planning. Pp. 197-211. Arthur, M. W., J. D. Hawkins, E. C. Brown, J. S. Briney, S. Oesterle, and R. D. Abbott. 2010. Implementation of the Communities That Care prevention system by coalitions in the Community Youth Development Study. Journal of Community Psychology 38:245-258. Bennett, G. G., L. H. McNeill, K. Y. Wolin, D. T. Duncan, E. Puleo, and K. M. Emmons. 2007. Safe to walk? Neighborhood safety and physical activity among public housing residents. PloS Medicine 4(10):1599-1607. Bollinger, C. R., and K. R. Ihlanfeldt. 2003. The intraurban spatial distribution of employ- ment: Which government interventions make a difference? Journal of Urban Economics 53(3):396-412. Boynton-Jarrett, R., J. Fargnoli, S. F. Suglia, B. Zuckerman, and R. J. Wright. 2010. Associa- tion between maternal intimate partner violence and incident obesity in preschool-aged children: Results from the fragile families and child well-being study. Archives of Pediat- rics & Adolescent Medicine 164(6):540-546. Brown, E. C., J. D. Hawkins, M. W. Arthur, J. S. Briney, and A. A. Fagan. 2011. Prevention service system transformation using Communities That Care. Journal of Community Psychology 39:183-201. Burdette, H. L., T. A. Wadden, and R. C. Whitaker. 2006. Neighborhood safety, collective efficacy, and obesity in women with young children. Obesity 14(3):518-525. Campbell, J. C. 2002. Health consequences of intimate partner violence. Lancet 359(9314): 1331-1336. Carver, A., A. Timperio, and D. Crawford. 2008. Perceptions of neighborhood safety and physical activity among youth: The CLAN study. Journal of Physical Activity & Health 5(3):430-444. Catalano, R. F., R. Kosterman, J. D. Hawkins, M. D. Newcomb, and R. D. Abbott. 1996. Modeling the etiology of adolescent substance use: A test of the social development model. Journal of Drug Issues 26(2):429-455. CDC (Centers for Disease Control and Prevention). 1999. Neighborhood safety and the prevalence of physical inactivity—Selected states, 1996. Morbidity and Mortality Weekly Report 48(07):143-146. CDC. 2007. The cost of violence in the United States. Atlanta, GA: Centers for Disease Con- trol and Prevention, National Centers for Injury Prevention and Control.

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