Since the Drug Free Schools and Communities Act of 1986, virtually all elementary and secondary schools provide some classroom programming on alcohol, tobacco and illicit drugs.
But do they work? The results so far have been mixed.
For example, a major longitudinal study in the Journal of the National Cancer Institute (JNCI) (Vol. 92, No. 24) last year confirmed researchers' doubts about social influences programs, which teach children to resist peer pressure and other influences and try to change their perceptions that many teens use drugs and smoke. In that study, researchers compared the social influences approach with control schools that conducted whatever drug and alcohol education was already occurring in the school. They found no differences between the two.
"This doesn't mean that everything is settled," explains University of Washington psychologist Irwin Sarason, PhD, one of the researchers, "But what it does provide is a wake up call to rethink the whole question of what we should be doing."
Research results like this do not signal failure, says psychologist Meyer Glantz, PhD, of the Division of Epidemiology Services and Prevention research at the National Institute on Drug Abuse (NIDA). "People forget that prevention is a young field," he explains.
Sure, there's a lot of room for the further development of prevention, say psychologists. But based on disappointments like those identified in the JNCI study and program successes, researchers have a clearer idea of the program elements that can successfully prevent drug and alcohol abuse--among them a combination of social influence, instructional and other treatments, such as teaching life skills and changing community norms about whether underage drinking and smoking are acceptable. They also know that curricula should be age-specific, span several years and include booster programs in high school.
"Now," says Glantz, "we're moving on the development of programs for specific problems or groups."
Daring to be different
Among the most visible prevention programs is the Drug Abuse Resistance Education (DARE) program. The elementary version, which is taught in roughly 75 percent of all U.S. schools, uses police officers to teach students about the physical and social effects of drug abuse. The goal was to build decision-making skills to help them resist drug abuse. But for all its good intentions, several studies found the elementary program alone had no effect on youth drug use. And while DARE offers programs for junior high and high school students, most schools do not offer these versions, despite growing evidence that elementary programs alone cannot impact use.
Building on lessons learned, DARE announced in February that it will study a new middle school and high school curriculum designed by sociologists Zili Sloboda, ScD, and Richard C. Stephens, PhD, at the University of Akron. The Robert Wood Johnson Foundation is funding the revamped program with a $13.7 million grant.
Drawing on the literature of effective substance abuse programs and from discussions with DARE police officers, Sloboda and curriculum specialists determined that DARE's initial program was undermined by too much information.
"There wasn't sufficient time allowed for the critical elements, therefore compelling the DARE officers to lecture and for the students to be more passive," explains Sloboda, former director of the Division of Epidemiology and Prevention Research at NIDA.
In response, the new program streamlines content, with emphasis on three areas: the normative beliefs of adolescents regarding substance abuse; perceptions of the social, psychological and health risks when using drugs and alcohol; and problem-solving, communication and assertiveness skills. With the content changes, DARE officers will now facilitate students' discussions rather than only instruct.
Teaching life skills and changing community norms
Researchers have also found that prevention programs are more effective when they blend social influence approaches with methods that teach self-management and social skills.
A prominent example of this approach is Life Skills Training, developed by psychologist Gilbert Botvin, PhD. Targeted toward middle school or junior high adolescents, the program focuses on enhancing teens general social competence, such as coping with stress and conversation skills. It also teaches students how to resist pressures from peers to smoke, drink and use drugs.
"Social influences assumes that kids engage in behaviors because they don't have the refusal skills and that they naturally want to say 'no,' but all kids don't want to say that," explains Botvin. "You have to go beyond that to a broader focus that targets a larger array of factors."
The program has been found to cut tobacco, alcohol and marijuana use roughly in half and pack-a-day smoking by 25 percent in suburban schools.
Other researchers are exploring approaches that seek to change community norms to combat drug and alcohol use. Researchers at the Pacific Institute for Research and Evaluation's Prevention Research Center, for example, have shown that a five-year, multifaceted community intervention reduced the harmful effects of high-risk alcohol consumption in three communities. Rather than targeting drinking per se, the interventions addressed environmental conditions and drinking patterns that are likely antecedents to trauma, such as responsible beverage service and sales, increasing law enforcement and media advocacy.
Five years later, the communities experienced substantial reductions in the quantity of alcohol consumed per occasion, and reports of "having too much to drink" declined by 49 percent.
"The effects on drinking seemed to be rising from general community efforts and a substantial change in community norms," notes researcher Peter Gruenwald, PhD. "The attitudes toward drinking shifted rather substantially." The study, funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), was published in Journal of the American Medical Association (Vol. 284, No. 18).
Other National Institute on Alcohol Abuse and Alcoholism-funded community prevention programs, such as Project Northland, developed by Cheryl L. Perry, PhD, Carolyn Williams, PhD, and colleagues, and Communities Mobilizing for Change on Alcohol, by Alexander C. Wagenaar, PhD, and David Murray, PhD, have also found that when communities mobilize, they can make a difference.
Northland, launched in 1991, was a 22-community randomized drinking prevention trial in Minnesota. It targeted young adolescents through a social and behavioral curriculum, peer leadership, parental involvement and education, and community-wide task force activities, such as passing ordinances for responsible alcohol sales or increasing law enforcement. After three years, students in the intervention schools reported less initiation of drinking, and drinking prevalence was lower in the intervention communities than comparison sites--especially among those who were nonusers at baseline.
Communities Mobilizing for Change on Alcohol targeted 18-to 20- year-olds by reducing alcohol availability to minors and changing adults and teen's social norms about underage drinking with the help of local government, law enforcement and media. Alcohol merchants increased age-ID checking and reduced selling to minors, particularly in bars and restaurants. The results? The target group reduced its propensity to provide alcohol to other teens, was less likely to try to buy alcohol, reported more difficulty getting alcohol and was less likely to drink within the past 30 days than those in the control communities.
The future of prevention
A variety of other research directions are topping psychologists' prevention study wish-list. They include:
Taking an ecological approach. Many psychologists believe it's essential to probe the idea that a person's choice to try drugs and to progress in substance use is the result of many interrelated factors.
"Until we begin to nest individuals in environmental contexts and look for how they interact to predict substance use we are probably not working with the entire set of causal factors," explains Richard Clayton, PhD, a sociology professor in the Kentucky School of Public Health.
He suggests that psychologists, anthropologists, neurobiologists, economists, communication specialists and other professionals collaborate to design, test and disseminate prevention programs that take into account the many influences in children's and adolescents' lives.
Layering programs. Broad prevention programs aren't always strong enough for children with multiple risk factors, such as children who exhibit problem behaviors and have alcoholic parents.
"We need to get some more research going on how to deal with high-risk youth because they're definitely a special population and we really do not have adequate preventions for them," says psychologist Gayle Boyd, PhD, program director for research on youth at NIAAA's Division of Clinical and Prevention Research.
Combining targeted interventions with broad prevention programs may be a more efficient way to reach at-risk children.
Including the family. Psychologists' research has repeatedly shown that families make a big impact in children's lives, and researchers are looking into how to harness that power in prevention efforts.
"To date, we have the indication that trying to do something with families is helpful, but there hasn't been any research that shows beneficial effects on drug abuse in family-based interventions," says NIDA's Glantz.
One promising program is Strengthening Families, developed by psychologist Karol Kumpfer, PhD, a former Center for Substance Abuse Prevention director and now a researcher at the University of Utah. The first version of Strengthening Families targeted children of substance users, but the program has now expanded its reach to an array of families. The program has been found to decrease children's impulsivity and intent to use substances and improve their behavior at home and in sibling relationships. In parents, the program has decreased drug use, stress, depression and use of corporal punishment, and increased parental efficacy.
Making new partners. While most prevention programs are based in schools, that may not be the best place to reach all teens, some researchers suggest. For example, Strengthening Families is run in churches, community centers, businesses and prisons as well as schools.
Another potential partner in prevention is the medical community. Family physicians can identify adolescents who are at-risk or using substances, and can help parents identify precursors and early signs of substance abuse.
"There are data that suggest that nurses and physicians acting as an adjunct to a school program can be useful," says sociologist Jan Howard, PhD, chief of the Prevention Research Branch at NIAAA's Division of Clinical Prevention and Research. "But what we don't really know is whether we can impact in a preventative way by somehow capturing HMOs and individual practitioners to do preventative work using their authority."
And since the health-care system has a limited involvement, Glantz also points to better interaction with the criminal justice system, which often serves as society's second line of institutional defense for drug abuse prevention and early intervention.
Improving dissemination, implementation and evaluation. Several government agencies are working to make science-based programs more readily available. CSAP is developing a national registry of science-based programs that are suitable for replication, including programs like Life Skills and Project Northland. NIDA and the U.S. Department of Education also cite model programs. Many also publish free in-depth materials for schools and parents, such as NIDA's "Preventing Drug Use among Children and Adolescents" and CSAP's "Keeping Youth Drug Free."
However, choosing a good program doesn't mean it will be effective.
"We need to look at what happens when you take programs out of the context of well-controlled studies and put them in the hands of local practitioners," says Botvin. And that includes not only helping schools overcome barriers to implementation, but also how the community evaluates the effectiveness of a program.
Expanding prevention's definition. No program or array of programs can stop everyone from initiating drug or alcohol use, explains Boyd. To help those who do progress, researchers should work to expand what's meant by prevention. For example, few programs are designed to help teens who are already experimenting with drugs and alcohol. Prevention programs and early treatment programs targeting escalation or progression could prevent early abusers from developing a drug abuse disorder or addiction, says Glantz.
And prevention efforts shouldn't stop at high school graduation. Instead, substance abuse education should be considered across the life span, says CSAP Director Ruth Sanchez-Way, PhD.
"We should be looking at all the different intervention points in a person's life," she explains. "From birth to death."
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