Sign in or 
- EasyEdit
- Edit tags
-
(what's this?What are these tools?
People just like you can add or edit the content on this site. If you want to try editing, but aren't ready to add to this site, try our demo area.
Read more about editing pages at Wetpaint Central.
) - Report page
Share this
Instruction to Prevent Substance Abuse (HS)
This summary discusses health education intended to prevent or reduce substance abuse as well as other addictions such as gambling. This page begins a discussion of formal classroom-based as well as informal educational activties (school assemblies and speakers, informal disucssions, poster campaigns etc) that can be delivered in schools. (Use the "Thread" tool at the bottom of the page) and/or to suggest research, resources, experts, examples and other information related to this point and sub-points. (Use the Easy Edit at the top of the page to add suggestions directly on the page).
Preventing substance abuse through school instruction and informal education programs
Smoking, alcohol and other drug use are the behaviours most commonly addressed in schools health education programs.[i] Like health education generally, alcohol and other drug education has evolved over the years. In its earliest form, drug education was based on the premise that young people only needed sound information in order to make healthy decisions. Typically these programs consisted of teachers presenting information on drug effects and dangers in the hope that the new knowledge would influence student behaviour. Although accurate, balanced drug-specific information is an important component of current good practice, the drug lectures that many grew up with are not effective (in fact they’ve been shown to be harmful in that they served to increase experimentation[ii]). These knowledge-based programs were replaced by affective education programs that focused on attitudes and values. These also failed to produce desired effects, perhaps because they were too abstract to truly engage young people – that is, they did not explicitly relate skill-building to drug-specific situations.[iii]
The next generation of drug education curriculum-based programs had stronger theoretic roots, drawing from Social Learning Theory[iv] and the Health Belief Model[v] among others. The two dominant models currently in use – the Social Influences Model and Competency Enhancement or Life Skills Model – are derived from these and have been the subject of numerous evaluations over the years.[vi] These evaluated programs (most of which originate in the U.S.) have been delivered mainly to junior high/middle school students and, to a lesser extent those in late elementary and senior high, and have aims that are typically abstinence-based. The inescapable conclusion, drawn by virtually all researchers, is that the best of these universal curriculum-based programs show only modest effectiveness, with even those effects eroding after a year or two, and that benefits may be limited to those least at risk[vii] [viii] [ix] [x] [xi] [xii] [xiii] [xiv] [xv] [xvi] [xvii]. This important conclusion has elicited or given voice to four quite different views from the research community on how school substance use prevention can be best advanced:
These perspectives do not necessarily exclude each other and together they represent the best current hopes for advancing the prevention of student substance use problems. They are accompanied by their own evidence-base; however universal classroom drug education has been subjected to much more empirical study than the other approaches. The state of the evidence for each will form the basis of this section of the knowledge summary.
Curriculum Design-Universal, Primary Prevention
Curriculum Design -Targeted, Secondary Prevention
Teacher/leader qualities & attitudes
Preventing substance abuse through school instruction and informal education programs
Smoking, alcohol and other drug use are the behaviours most commonly addressed in schools health education programs.[i] Like health education generally, alcohol and other drug education has evolved over the years. In its earliest form, drug education was based on the premise that young people only needed sound information in order to make healthy decisions. Typically these programs consisted of teachers presenting information on drug effects and dangers in the hope that the new knowledge would influence student behaviour. Although accurate, balanced drug-specific information is an important component of current good practice, the drug lectures that many grew up with are not effective (in fact they’ve been shown to be harmful in that they served to increase experimentation[ii]). These knowledge-based programs were replaced by affective education programs that focused on attitudes and values. These also failed to produce desired effects, perhaps because they were too abstract to truly engage young people – that is, they did not explicitly relate skill-building to drug-specific situations.[iii]
The next generation of drug education curriculum-based programs had stronger theoretic roots, drawing from Social Learning Theory[iv] and the Health Belief Model[v] among others. The two dominant models currently in use – the Social Influences Model and Competency Enhancement or Life Skills Model – are derived from these and have been the subject of numerous evaluations over the years.[vi] These evaluated programs (most of which originate in the U.S.) have been delivered mainly to junior high/middle school students and, to a lesser extent those in late elementary and senior high, and have aims that are typically abstinence-based. The inescapable conclusion, drawn by virtually all researchers, is that the best of these universal curriculum-based programs show only modest effectiveness, with even those effects eroding after a year or two, and that benefits may be limited to those least at risk[vii] [viii] [ix] [x] [xi] [xii] [xiii] [xiv] [xv] [xvi] [xvii]. This important conclusion has elicited or given voice to four quite different views from the research community on how school substance use prevention can be best advanced:
[a] given the range of harms linked to early substance use, delay of use by even a year or two can have important public health benefit and is worth pursuing[xviii];
[b] achieving abstinence for all students is unrealistic; consider other positive substance use outcomes in addition to abstinence[xix] [xx]; [c] focus efforts on higher risk students rather than or in addition to the general (universal) student population[xxi]; and [d] attention to curriculum is necessary but not sufficient – it needs to be couched in a whole-school, comprehensive approach.[xxii]
These perspectives do not necessarily exclude each other and together they represent the best current hopes for advancing the prevention of student substance use problems. They are accompanied by their own evidence-base; however universal classroom drug education has been subjected to much more empirical study than the other approaches. The state of the evidence for each will form the basis of this section of the knowledge summary.
[i] Lynagh, M., Schofield, M.J., & Sanson-Fisher, R.W. (1997). School health promotion programs over the past decade: A review of the smoking, alcohol and solar protection literature. Health Promotion International, 12(1).
[ii] Goodstadt, M. (1990). School-based drug education research findings: What have we learned? What can be done? Prevention research findings: 1988. Rockville, MD.: Office of Substance Abuse Prevention.
[iii] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50.
[iv] Bandura, 1977 (as cited in Loxley, W., Toumbourou, J.W., and Stockwell, T. (2004). The prevention of substance use, risk and harm in Australia: A review of the evidence. Retrieved September 30, 2007, from http://www.health.gov.au/internet/wcms/publishing.nsf/content/health-pubhlth-publicat-document-mono_prevention-cnt.htm/$FILE/mono_prevention.pdf
[v] Nancy, K., Janz, R.N., Marshall, M.S., & Becker, H. (1984). The health belief model: A decade later. Health Education & Behavior, 11(1), 1-47.
[vi] Skara, S., & Sussman, S. (2003). A review of 25 long-term adolescent tobacco and other drug use prevention program evaluations. Preventive Medicine, 37, 451-474.
[vii] Nation, M., Crusto, C., Wandersman, A., Kumpfer, K.L., Seybolt, D., Morrissey-Kane, E., & Davino, K. (2003). What works in prevention. Principles of effective prevention programs. American Psychologist, 58(6/7), 449–456.
[viii] Foxcroft, D., Ireland, D.J., Lister-Sharp, D., Lowe, G., & Breen, R. (2003). Longer-term primary prevention for alcohol misuse in young people: A systematic review. Addiction, 98, 397-411.
[ix] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50.
[x] White, D., & Pitts, M. (1998). Educating young people about drugs: A systematic review. Addiction, 93(10), 1475-1487.
[xi] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[xii] Lynagh, M., Schofield, M.J., & Sanson-Fisher, R.W. (1997). School health promotion programs over the past decade: A review of the smoking, alcohol and solar protection literature. Health Promotion International, 12(1).
[xiii] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf
[xiv] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38.
[xv] Skara, S., & Sussman, S. (2003). A review of 25 long-term adolescent tobacco and other drug use prevention program evaluations. Preventive Medicine, 37, 451-474.
[xvi] Ross, C., Richard, L., & Potvin, L. (1998). One year outcome evaluation of an alcohol and drug abuse prevention program in a Quebec high school. Canadian Journal of Public Health, 89(3), 166-170.
[xvii] Patton, G., Bond, L., Carlin, J., Thomas, L., Butler, H. et al. (2006). Promoting social inclusion in schools: A group-randomized trial of effects on student health risk behavior and well-being. American Journal of Public Health, 96(9).
[xviii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[xix] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[xx] McBride, N., & Farringdon, F. (2004). School health and alcohol harm reduction project: Changing students’ alcohol related behaviors through classroom lessons in Western Australia. Education and Health, 22(2), 19-23.
[xxi] Stewart, S.H., Conrod, P.J., Allan, G., Marlatt, M., Comeau, N., Thush, C., & Krank, M. (2005). New developments in prevention and early intervention for alcohol abuse in youths. Alcoholism: Clinical and Experimental Research, 29(2).
[xxii] Stewart-Brown, S. (2006). What is the evidence on school health promotion in improving health or preventing disease and, specifically, what is the effectiveness of the health promoting schools approach? Geneva, Switzerland: World Health Organization.
Effective curriculum, instruction and student assessment includes a age-appropriate, well-scoped, sequential curricula, high quality, up-to-date teaching/learning materials, a wide variety of teaching methods including experiential and cooperative learning and a variety of forms of instruction, the use of the Internet and new media, parental involvement in take home learning activities, peer-led educational activities and careful use of external presenters. Curriculum, instruction and assessment should be supported by regular monitoring/reporting on student learning of skills and knowledge pre-service teacher training and ongoing teacher development based on adult learning principles within a reflective practice, social learning approach.
Application to school substance abuse prevention
(Contributors are invited to add statements of good practice or to identify implications related to the point being made on this page.)
Base instruction on social influences model
Effective curriculum, instruction and student assessment includes a age-appropriate, well-scoped, sequential curricula, high quality, up-to-date teaching/learning materials, a wide variety of teaching methods including experiential and cooperative learning and a variety of forms of instruction, the use of the Internet and new media, parental involvement in take home learning activities, peer-led educational activities and careful use of external presenters. Curriculum, instruction and assessment should be supported by regular monitoring/reporting on student learning of skills and knowledge pre-service teacher training and ongoing teacher development based on adult learning principles within a reflective practice, social learning approach.
Application to school substance abuse prevention
(Contributors are invited to add statements of good practice or to identify implications related to the point being made on this page.)
- Good/promising practice 5: at the junior/middle school level particularly, annually deliver universal substance education based on the Social Influences Model; this model can create a greater awareness of media and social influences, and help students develop skills to analyze and minimize their impact. Within this approach, accurate information that is free of moralizing needs to be available to students. (Canadian Association for School Health, p.25) Go to Base instruction on social influences model for a discussion of this practice.
- Good/promising practice 6: universal substance education needs to emphasize student-to-student, rather than student-to-teacher, interactivity; this may involve role-plays, Socratic questioning, simulations, brainstorming, cooperative learning, peer-to-peer discussion and service-learning projects. (Canadian Association for School Health, p. 25) Go to Interactive teaching/learning methods to discuss this practice.
- Good/promising practice 7: classroom lessons are best led by teachers or leaders that are comfortable with and have competence in promoting interactivity among students on substance use issues. Teachers / leaders need to create a non-judgmental atmosphere in order to effectively lead these activities. (Canadian Association for School Health, p.30) Go to Teacher/leader qualities & attitudes for a discussion of this practice.
- Good/promising practice CICAD 3 Recommend that the school-based prevention strategy include, in the framework of the national plan, education programs at all levels (pre-school, primary, secondary and university) in a gradual, continuous and systematic process. (Organization of the American States)
- Good/promising practice CICAD 17. Include promotion of healthy lifestyles, development of life skills, and substance abuse prevention as cross-cutting core priorities or objectives of school curricula. (Organization of the American States)
- Good/promising practice CICAD 18 In addition to issues included as cross-cutting themes of basic education programs, there is a need also to implement specific programs during school hours. The reason for this is that it is sometimes thought that the task can be accomplished simply through cross-cutting inclusion, when in fact it has been shown that that alone is not sufficient. (Organization of the American States)
- Good/promising practice UNODC Principle 5. Teaching and learning should be interactive. Interactive teaching techniques such as discussions, brainstorming, decision-making, assertion training or role-playing new skills and behaviour stimulate the active participation of all students. A supportive classroom climate is promoted by conducting activities in smaller groups, which encourages peer to peer communication and maximum participation. (UN Office on Drugs & Crime)
- Good/promising practice UNODC Principle 6. Educational programmes for the prevention of drug abuse should be responsive and inclusive Educational programmes for the prevention of drug abuse should take into account levels of drug use among individuals and in society, risk and protective factors, gender, ethnicity, culture, language, developmental level, ability level, religion and sexual orientation. Interacting with students in a way that acknowledges the reality of their backgrounds and experiences creates opportunities for meaningful student input into education for drug abuse prevention programmes. Students react positively when their individual needs and the needs of users and non-users are acknowledged and communication channels are kept open without drug use being condoned. (UN Office on Drugs & Crime)
- Good/promising practice UNOCD school-based education for drug abuse prevention forms a core component of the school curriculum and focuses on equipping young people with information about drugs, the life skills necessary to enable them to deal with different situations without turning to drugs, the ability to resist pressure to use drugs and an understanding of what drugs are. (UN Office on Drugs & Crime)
Base instruction on social influences model
This page discusses universal drug education programs based on variations of social influences behavioural theories.
The vast majority of the student substance abuse prevention programs that have been evaluated are universal curriculum-based programs. The benefits of even the most effective of these drug education programs tend to erode. Studies show that groups that receive what is usually a 10-session program is generally found to be using substances at a similar rate to comparison groups one or two years following the completion of the program. Some observers see this as an indictment on drug education programs, while others suggest that it is not surprising that the effects do not last too long considering the various influences at play in the lives of youth.[i] They contend that even a delay in use or reduced use over one or two adolescent years is an important contribution during a period when use can be particularly risky and prevalence rates escalate quickly. Seen in this light, the erosion effect simply highlights the need for yearly attention to the issue in the classroom and ongoing research to better understand the most effective components of these programs.
Many of the factors that can influence youthful substance use lie beyond the school grounds. When attempting to support young people in navigating through adolescence with a minimum of substance-related harm, educators and community members are up against major societal forces. Among the many individual, social, and cultural factors that can come into play as a young person makes his or her way to adulthood, teachers are in a position to influence only a few of these factors through curriculum and instruction.[ii] The opportunities lie in the realm of understanding and coping effectively with social influences that promote substance use, and supporting the development of pertinant personal and social skills (e.g., assertiveness, decision-making and stress management).[iii] [iv]
Social influence programs
The Social Influences Model conceptualizes adolescent use of substances to be the result of influences from family, peers and the media.[v] These influences may be in the form of substance use by family, peers and media personalities or messages condoning or encouraging use. This model aims to create greater awareness of the various influences, and to help students develop skills to analyze and minimize their impact on their substance use.
In its earliest forms, social influence programs included a component referred to as psychological inoculation, which exposed students to increasingly persuasive pro-drug messages as a way of inoculating them or building resistance to real-life drug-related messages. Studies have not shown inoculation to contribute to the effectiveness of drug education, so more recent program designs do not include this element.[vi]
An element of social influence programs that continues to be popular is resistance skills training. This element is based on the assumption that adolescents begin to use substances largely because they lack the confidence or skills to resist social influences to smoke, drink, or use other drugs. Therefore, this approach focuses on identifying instances when these types of influences are at play. Emphasis is often placed on teaching students to identify the techniques used by advertisers to influence consumer behaviour. Once these instances and messages are recognized and identified, students can be taught tactics for dealing with the messages. For example, students may be made more aware of advertising designed to sell tobacco products or alcoholic beverages and given the chance to formulate counter-arguments. Similarly, they learn about various situations involving peer influence, and develop a repertoire of responses to the influences. Attention is paid to the content of responses, their tone, and accompanying body language.[vii]
Resistance skills training is controversial in the research community in that some continue to advocate its use while others contend that a portion of it is based on a faulty assumption.[viii] [ix] The evidence indicates that peer pressure has been exaggerated as a causal factor in risk behaviours. First of all, anyone who begins to use a substance, including young people, does so for a variety of reasons, and to fulfill a range of needs. The influence is often nuanced and might be better termed ‘peer preference,’ with a young person picking a peer group on the basis of its preferences on a number of fronts, such as music, clothing, use of substances, or social justice concerns.[x] While they may not have been pressured into using by peers, they may be pressured not to quit, or to drink or use to a certain level.[xi] [xii] A common element of this approach for which there is no scientific evidence is making a public commitment not to smoke, drink, and/or use other substances.[xiii] Cuipers (2002) concluded that research has not found resistance skills training to contribute to the effectiveness of programs.[xiv] In their meta-analysis, Roona et al. (2000) found that interactive middle school drug education programs that did not teach refusal skills were just as effective as interactive middle school programs that did so.[xv]
An element in social influence programming that is better supported by scientific evidence is normative education. [xvi] [xvii] It is commonly accepted that young people tend to overestimate the prevalence of smoking, drinking, and other drug use among other adolescents and adults. This leads to an inaccurate sense of how ‘normal,’ or accepted alcohol and other drug use is in a young person’s school, neighbourhood, or community. Normative approaches are designed to correct the misperception that ‘everyone is doing it.’ A method that has been used to modify or correct normative expectations involves providing students with information about the prevalence of drug use from national or local surveys. Since the actual rates of substance use in most classes, schools, and communities is consistently quite a bit lower than adolescents believe, this activity helps correct misperceptions and shift norms.
However, this approach can obviously only work with substances and student populations where the percentage of users is in fact relatively low (for example, less than 40% of students using in the past year).[xviii] Using the 40% benchmark with Ontario students (because of the availability of recent data), normative education would have been appropriate in 2005 for alcohol in Grades 7 and 8, cannabis in Grades 7-10 and tobacco in Grades 7-12.
The logic of a normative approach also applies to hazardous use (rather than any use per se). Norms around hazardous behaviours, such as binge drinking or riding with someone who is impaired, could also be the focus of normative education, if supporting data are available. There is some evidence from a meta-analysis that normative education is effective in reducing incidents of heavy drinking at the junior high school level.[xix] More recently, Agostinelli and Grube (2002) tested two versions of a normative approach against a control in a randomized sample of older high school students in the U.S. With one version, students were provided with information about student drinking patterns in their locale; in the second, students received this information along with personalized information comparing their own drinking patterns against the norm, while the control students received neither. Both approaches were effective in reducing the tendency to underestimate the number of students who did not engage in heavy drinking, but only the personalized approach resulted in students adopting more conservative personal standards.[xx]
Media-based campaigns addressing perceptions of “social norms” have become prevalent, particularly among post-secondary institutions in the U.S., and also in Canada.[xxi] One caution deserves note. When reviewing the broader literature on these social norm campaigns, Shultz and colleagues (2007) have found mixed results and suggest this may be because people measure the appropriateness of their behaviour by how far away they are from the norm – consequently students not using alcohol or drinking below the norm might see themselves as “deviant”. Although the majority of students do overestimate the prevalence of alcohol consumption, some actually underestimate its prevalence. So, normative information might have the unintended boomerang effect of inducing more alcohol use among those that had underestimated its prevalence.[xxii]
The review by Shultz and colleagues focused on media-based campaigns, but it is possible this problem could arise with school instructional programs also. It is apparent that a good knowledge of students’ perceptions is important when using a social norms approach and that care be taken to construct a message that is health promoting for all students.[xxiii]
Competency Enhancement Model
The second model that has been extensively studied and receives some support in the literature is the Competency Enhancement Model.[xxiv] This model emphasizes the teaching of generic personal and social skills either alone or in combination with elements of the social influence approach. These skills are taught using a combination of well-supported cognitive-behavioural skills training methods that can include instruction and demonstration, behavioural rehearsal (in-class practice), feedback and reinforcement, and out-of-class practice through behavioural homework assignments. The personal and social skills typically included in competence enhancement approaches are decision-making and problem-solving skills, cognitive skills for resisting peer and media influences, skills for increasing personal control and enhancing self esteem (e.g., goal-setting and self-directed behaviour change techniques), coping strategies for managing stress and anxiety, and assertive skills. This approach has been a common element in prevention programs to help young people address a number of issue areas (e.g., mental health, sexuality). Proponents of this approach however claim that the approach is only effective in reducing youth substance use if the skills practice and development are tied directly to drug-related situations or scenarios (rather than generic scenarios).[xxv]
Historically, competence enhancement programs have been held to be more effective than social influence programs.[xxvi] [xxvii] However, Roona and colleagues (2000), in their meta-analysis of 128 interactive drug education programs, found that competence enhancement approaches were no more effective than social influence programs, and at the middle school level were in fact, less effective. Also, the most visible of the competence enhancement programs, Botvin’s Life Skills Training (LST) program has been criticized by several reviewers on a number of grounds, including failing to report negative results on alcohol use, as well as for issues surrounding sample selection and attrition.[xxviii] [xxix] [xxx] [xxxi] A recent test of two delivery methods of the LST program by researchers independent of the program found neither method to be better than no program at all.[xxxii]
Foxcroft (2003), employing the stringent standards of the Cochrane Collaboration, concluded that the evidence for long-term effectiveness (> 3 yrs) of the Life Skills Training (LST) program is not very convincing for alcohol prevention.[xxxiii] McGrath and colleagues (2006) suggested that the positive effects found with LST are mainly limited to legal substances and confined to students whose drug use is already low, and/or to those who received the complete program (hence likely to exclude those students already using drugs or those at most risk).[xxxiv] The meta-analysis by Tobler et al. (2000) found that adding life-skills training to social influence programs may strengthen the effects of prevention programs.[xxxv]
Curriculua for universal student populations
The vast majority of the student substance abuse prevention programs that have been evaluated are universal curriculum-based programs. The benefits of even the most effective of these drug education programs tend to erode. Studies show that groups that receive what is usually a 10-session program is generally found to be using substances at a similar rate to comparison groups one or two years following the completion of the program. Some observers see this as an indictment on drug education programs, while others suggest that it is not surprising that the effects do not last too long considering the various influences at play in the lives of youth.[i] They contend that even a delay in use or reduced use over one or two adolescent years is an important contribution during a period when use can be particularly risky and prevalence rates escalate quickly. Seen in this light, the erosion effect simply highlights the need for yearly attention to the issue in the classroom and ongoing research to better understand the most effective components of these programs.
Many of the factors that can influence youthful substance use lie beyond the school grounds. When attempting to support young people in navigating through adolescence with a minimum of substance-related harm, educators and community members are up against major societal forces. Among the many individual, social, and cultural factors that can come into play as a young person makes his or her way to adulthood, teachers are in a position to influence only a few of these factors through curriculum and instruction.[ii] The opportunities lie in the realm of understanding and coping effectively with social influences that promote substance use, and supporting the development of pertinant personal and social skills (e.g., assertiveness, decision-making and stress management).[iii] [iv]
Social influence programs
The Social Influences Model conceptualizes adolescent use of substances to be the result of influences from family, peers and the media.[v] These influences may be in the form of substance use by family, peers and media personalities or messages condoning or encouraging use. This model aims to create greater awareness of the various influences, and to help students develop skills to analyze and minimize their impact on their substance use.
In its earliest forms, social influence programs included a component referred to as psychological inoculation, which exposed students to increasingly persuasive pro-drug messages as a way of inoculating them or building resistance to real-life drug-related messages. Studies have not shown inoculation to contribute to the effectiveness of drug education, so more recent program designs do not include this element.[vi]
An element of social influence programs that continues to be popular is resistance skills training. This element is based on the assumption that adolescents begin to use substances largely because they lack the confidence or skills to resist social influences to smoke, drink, or use other drugs. Therefore, this approach focuses on identifying instances when these types of influences are at play. Emphasis is often placed on teaching students to identify the techniques used by advertisers to influence consumer behaviour. Once these instances and messages are recognized and identified, students can be taught tactics for dealing with the messages. For example, students may be made more aware of advertising designed to sell tobacco products or alcoholic beverages and given the chance to formulate counter-arguments. Similarly, they learn about various situations involving peer influence, and develop a repertoire of responses to the influences. Attention is paid to the content of responses, their tone, and accompanying body language.[vii]
Resistance skills training is controversial in the research community in that some continue to advocate its use while others contend that a portion of it is based on a faulty assumption.[viii] [ix] The evidence indicates that peer pressure has been exaggerated as a causal factor in risk behaviours. First of all, anyone who begins to use a substance, including young people, does so for a variety of reasons, and to fulfill a range of needs. The influence is often nuanced and might be better termed ‘peer preference,’ with a young person picking a peer group on the basis of its preferences on a number of fronts, such as music, clothing, use of substances, or social justice concerns.[x] While they may not have been pressured into using by peers, they may be pressured not to quit, or to drink or use to a certain level.[xi] [xii] A common element of this approach for which there is no scientific evidence is making a public commitment not to smoke, drink, and/or use other substances.[xiii] Cuipers (2002) concluded that research has not found resistance skills training to contribute to the effectiveness of programs.[xiv] In their meta-analysis, Roona et al. (2000) found that interactive middle school drug education programs that did not teach refusal skills were just as effective as interactive middle school programs that did so.[xv]
An element in social influence programming that is better supported by scientific evidence is normative education. [xvi] [xvii] It is commonly accepted that young people tend to overestimate the prevalence of smoking, drinking, and other drug use among other adolescents and adults. This leads to an inaccurate sense of how ‘normal,’ or accepted alcohol and other drug use is in a young person’s school, neighbourhood, or community. Normative approaches are designed to correct the misperception that ‘everyone is doing it.’ A method that has been used to modify or correct normative expectations involves providing students with information about the prevalence of drug use from national or local surveys. Since the actual rates of substance use in most classes, schools, and communities is consistently quite a bit lower than adolescents believe, this activity helps correct misperceptions and shift norms.
However, this approach can obviously only work with substances and student populations where the percentage of users is in fact relatively low (for example, less than 40% of students using in the past year).[xviii] Using the 40% benchmark with Ontario students (because of the availability of recent data), normative education would have been appropriate in 2005 for alcohol in Grades 7 and 8, cannabis in Grades 7-10 and tobacco in Grades 7-12.
The logic of a normative approach also applies to hazardous use (rather than any use per se). Norms around hazardous behaviours, such as binge drinking or riding with someone who is impaired, could also be the focus of normative education, if supporting data are available. There is some evidence from a meta-analysis that normative education is effective in reducing incidents of heavy drinking at the junior high school level.[xix] More recently, Agostinelli and Grube (2002) tested two versions of a normative approach against a control in a randomized sample of older high school students in the U.S. With one version, students were provided with information about student drinking patterns in their locale; in the second, students received this information along with personalized information comparing their own drinking patterns against the norm, while the control students received neither. Both approaches were effective in reducing the tendency to underestimate the number of students who did not engage in heavy drinking, but only the personalized approach resulted in students adopting more conservative personal standards.[xx]
Media-based campaigns addressing perceptions of “social norms” have become prevalent, particularly among post-secondary institutions in the U.S., and also in Canada.[xxi] One caution deserves note. When reviewing the broader literature on these social norm campaigns, Shultz and colleagues (2007) have found mixed results and suggest this may be because people measure the appropriateness of their behaviour by how far away they are from the norm – consequently students not using alcohol or drinking below the norm might see themselves as “deviant”. Although the majority of students do overestimate the prevalence of alcohol consumption, some actually underestimate its prevalence. So, normative information might have the unintended boomerang effect of inducing more alcohol use among those that had underestimated its prevalence.[xxii]
The review by Shultz and colleagues focused on media-based campaigns, but it is possible this problem could arise with school instructional programs also. It is apparent that a good knowledge of students’ perceptions is important when using a social norms approach and that care be taken to construct a message that is health promoting for all students.[xxiii]
Competency Enhancement Model
The second model that has been extensively studied and receives some support in the literature is the Competency Enhancement Model.[xxiv] This model emphasizes the teaching of generic personal and social skills either alone or in combination with elements of the social influence approach. These skills are taught using a combination of well-supported cognitive-behavioural skills training methods that can include instruction and demonstration, behavioural rehearsal (in-class practice), feedback and reinforcement, and out-of-class practice through behavioural homework assignments. The personal and social skills typically included in competence enhancement approaches are decision-making and problem-solving skills, cognitive skills for resisting peer and media influences, skills for increasing personal control and enhancing self esteem (e.g., goal-setting and self-directed behaviour change techniques), coping strategies for managing stress and anxiety, and assertive skills. This approach has been a common element in prevention programs to help young people address a number of issue areas (e.g., mental health, sexuality). Proponents of this approach however claim that the approach is only effective in reducing youth substance use if the skills practice and development are tied directly to drug-related situations or scenarios (rather than generic scenarios).[xxv]
Historically, competence enhancement programs have been held to be more effective than social influence programs.[xxvi] [xxvii] However, Roona and colleagues (2000), in their meta-analysis of 128 interactive drug education programs, found that competence enhancement approaches were no more effective than social influence programs, and at the middle school level were in fact, less effective. Also, the most visible of the competence enhancement programs, Botvin’s Life Skills Training (LST) program has been criticized by several reviewers on a number of grounds, including failing to report negative results on alcohol use, as well as for issues surrounding sample selection and attrition.[xxviii] [xxix] [xxx] [xxxi] A recent test of two delivery methods of the LST program by researchers independent of the program found neither method to be better than no program at all.[xxxii]
Foxcroft (2003), employing the stringent standards of the Cochrane Collaboration, concluded that the evidence for long-term effectiveness (> 3 yrs) of the Life Skills Training (LST) program is not very convincing for alcohol prevention.[xxxiii] McGrath and colleagues (2006) suggested that the positive effects found with LST are mainly limited to legal substances and confined to students whose drug use is already low, and/or to those who received the complete program (hence likely to exclude those students already using drugs or those at most risk).[xxxiv] The meta-analysis by Tobler et al. (2000) found that adding life-skills training to social influence programs may strengthen the effects of prevention programs.[xxxv]
[i] McBride, N. (2004). School drug education: A developing field and one element in a community approach to drugs and young people: A response to the commentaries. Addiction, 99(3), 296.
[ii] Flay, B.R. (2000). Approaches to substance use prevention utilizing school curriculum plus social environment change. Addictive Behaviors, 25(6), 861-885.
[iii] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023.
[iv] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[v] Flay, B.R., & Petraitis, J. (1994). The theory of triadic influence. A new theory of health behavior with implications for preventative interventions. Advances in Medical Sociology, 4, 19-44.
[vi] Botvin, G. J. (2000). Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors, 25(6), 887-897.
[vii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[viii] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50.
[ix] Allott, R., Paxton, R., & Leonard, R. (1999). Drug education: A review of British government policy and evidence on effectiveness. Health Education Research: Theory & Practice, 14(4), 491-505.
[x] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50.
[xi] Allen & Clarke Policy and Regulatory Specialists Ltd. (2003). Effective drug education for young people: Literature review and analysis. Retrieved August 31, 2007, from http://www.myd.govt.nz/uploads/docs/0.7.1.1%20effective%20drug%20ed.pdf
[xii] Sheppard, M.A., Wright, D., & Goodstadt, M.S. (1985). Drug use and peer pressure: Exploding the myth. Adolescence, 20(80), 949-958.
[xiii] Botvin, G. J. (2000). Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors, 25(6), 887-897.
[xiv] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023.
[xv] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[xvi] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023.
[xvii] Hansen, W., & Graham, J. (1991). Preventing alcohol, marijuana, and cigarette use among adolescents: Peer pressure resistance training versus establishing conservative norms. Preventive Medicine, 20(3), 414-430.
[xviii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[xix] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[xx] Agostinelli, G. & Grube, J. (2002). Alcohol counter-advertising and the media: A review of recent research. Alcohol Research and Health, 26(1), 15-21.
[xxi] Perkins, H., Haines, M., and Rice, R. (2005). Misperceiving the college drinking norm and related problems: A nationwide study of exposure to prevention information, perceived norms and student alcohol misuse. Journal of Studies on Alcohol, 66, 470-478.
[xxii] Schultz, W., Nolan, J., Cialdini, R., Goldstein, N., Griskevicius, V. (2007). The Constructive, Destructive, and Reconstructive Power of Social Norms. Psychological science, 18(5).
[xxiii] Granfield, R. (2004). Alcohol use in college: Limitations on the transformation of social norms. Addiction Research and Theory, 13(3), 281–292.
[xxiv] Botvin, G. J. (2000). Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors, 25(6), 887-897.
[xxv] ibid
[xxvi] Tobler, N.S., & Stratton, H.H. (1997). Effectiveness of school-based drug prevention programs: A meta-analysis of the research. The Journal of Primary Prevention, 18(1), 71-128.
[xxvii] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[xxviii] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50.
[xxix] Coggans, N., Cheyne, B., & McKellat, S. (2002). The life skills training drug education programme: A review of research. Retrieved August 31, 2007, from http://www.drugmisuse.isdscotland.org/eiu/pdfs/eiu_lifeskl.pdf
[xxx] Foxcroft, D., Ireland, D.J., Lister-Sharp, D., Lowe, G., & Breen, R. (2003). Longer-term primary prevention for alcohol misuse in young people: A systematic review. Addiction, 98, 397-411.
[xxxi] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf
[xxxii] Vicary, J.R., Smith, E.A., Swisher, J.D., Bechtel, L.J., Elek, E., Henry, K.L., et al. (2006). Results of a 3-year study of two methods of delivery of life skills training. Health education behavior, 33(3), 325-339.
[xxxiii] Foxcroft, D., Ireland, D.J., Lister-Sharp, D., Lowe, G., & Breen, R. (2003). Longer-term primary prevention for alcohol misuse in young people: A systematic review. Addiction, 98, 397-411.
[xxxiv] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf
[xxxv] Tobler, N.S. (2000). Lessons learned. The Journal of Primary Prevention, 20(4), 261-274.
Curriculum Design-Universal, Primary Prevention
Curriculum for universal student populations to prevent problem substance use
An excerpt from, "School-based and school-linked prevention of substance use problems: A knowledge summary", Canadian Association for School Health, 2008.
The vast majority of the student substance abuse prevention programs that have been evaluated are universal curriculum-based programs. The benefits of even the most effective of these drug education programs tend to erode. Studies show that groups that receive what is usually a 10-session program are generally found to be using substances at a similar rate to comparison groups one or two years following the completion of the program. Some observers see this as a failure of drug education, while others suggest that it is not surprising that the effects do not last too long considering the various influences at play in the lives of youth.[i] They contend that even a delay in use or reduced use over one or two adolescent years is an important contribution during a period when use can be particularly risky and prevalence rates escalate quickly. Seen in this light, the erosion effect simply highlights the need for yearly attention to the issue in the classroom and ongoing research to better understand the most effective components of these programs. Many of the factors that can influence youthful substance use lie beyond the school grounds. When attempting to support young people in navigating through adolescence with a minimum of substance-related harm, educators and community members are up against major societal forces. Among the many individual, social, and cultural factors that can come into play as a young person makes his or her way to adulthood, teachers are in a position to influence only a few of these factors through curriculum and instruction.[ii] The opportunities lie in the realm of understanding and coping effectively with social influences that promote substance use, and supporting the development of pertinent personal and social skills (e.g., assertiveness, decision-making and stress management).[iii] [iv]
Social influence programs The Social Influences Model views adolescent use of substances to be the result of influences from family, peers and the media.[v] These influences may be in the form of substance use by family, peers and media personalities or messages condoning or encouraging use. This model aims to create greater awareness of the various influences, and to help students develop skills to analyze and minimize their impact on their substance use. In their earliest forms, social influence programs included a component referred to as psychological inoculation, which exposed students to increasingly persuasive pro-drug messages as a way of inoculating them or building resistance to real-life drug-related messages. Studies have not shown inoculation to contribute to the effectiveness of drug education, so more recent program designs do not include this element.[vi]
An element of social influence programs that continues to be popular is resistance skills training. This element is based on the assumption that adolescents begin to use substances largely because they lack the confidence or skills to resist social influences to smoke, drink, or use other drugs. Therefore, this approach focuses on identifying instances when these types of influences are at play. Emphasis is often placed on teaching students to identify the techniques used by advertisers to influence consumer behaviour. Once these instances and messages are recognized and identified, students can be taught tactics for dealing with the messages. For example, students may be made more aware of advertising designed to sell tobacco products or alcoholic beverages and given the chance to formulate counter-arguments. Similarly, they learn about various situations involving peer influence, and develop a repertoire of responses to the influences. Attention is paid to the content of responses, their tone, and accompanying body language.[vii] Resistance skills training is controversial in the research community in that some continue to advocate its use while others contend that a portion of it is based on a faulty assumption.[viii] [ix] The evidence indicates that peer pressure has been exaggerated as a causal factor in risk behaviours. First of all, anyone who begins to use a substance, including young people, does so for a variety of reasons, and to fulfill a range of needs. The influence is often nuanced and might be better termed ‘peer preference,’ or ‘peer selection’ with a young person picking a peer group on the basis of its preferences on a number of fronts, such as music, clothing, use of substances, or social justice concerns.[x] While they may not have been pressured into using by peers, they may be pressured not to quit, or to drink or use at a certain level.[xi] [xii] A common element of this approach for which there is no scientific evidence is making a public commitment not to smoke, drink, and/or use other substances.[xiii] Cuipers (2002) concluded that research has not found resistance skills training to contribute to the effectiveness of programs.[xiv] In their meta-analysis, Roona et al. (2000) found that interactive middle school drug education programs that did not teach refusal skills were just as effective as interactive middle school programs that did so.[xv]
An element in social influence programming that is better supported by scientific evidence is normative education. [xvi] [xvii] It is commonly accepted that young people tend to overestimate the prevalence of smoking, drinking, and other drug use among other adolescents and adults. This leads to an inaccurate sense of how ‘normal,’ or accepted alcohol and other drug use is in a young person’s school, neighbourhood, or community. Normative approaches are designed to correct the misperception that ‘everyone is doing it.’ A method that has been used to modify or correct normative expectations involves providing students with information about the prevalence of drug use from national or local surveys. Since the actual rates of substance use in most classes, schools, and communities is consistently quite a bit lower than adolescents believe, this activity helps correct misperceptions and shift norms. However, this approach can obviously only work with substances and student populations where the percentage of users is in fact relatively low (for example, less than 40% of students using in the past year).[xviii] Because rates of use for common substances increase rapidly through the middle/high school years, it is important that age-specific data be used for these purposes. Using the 40% benchmark with Ontario students (because of the availability of recent data), normative education would have been appropriate in 2007 for alcohol in Grades 7 and 8, cannabis in Grades 7-10 and tobacco in Grades 7-12.
The logic of a normative approach also applies to hazardous use (rather than any use per se). Norms around hazardous behaviours, such as binge drinking or riding with someone who is impaired, could also be the focus of normative education, if supporting data are available. There is some evidence from a meta-analysis that normative education is effective in reducing incidents of heavy drinking at the junior high school level.[xix] More recently, Agostinelli and Grube (2002) tested two versions of a normative approach against a control in a randomized sample of older high school students in the U.S. With one version, students were provided with information about student drinking patterns in their locale; in the second, students received this information along with personalized information comparing their own drinking patterns against the norm, while the control students received neither. Both approaches were effective in reducing the tendency to underestimate the number of students who did not engage in heavy drinking, but only the personalized approach resulted in students adopting more conservative personal standards.[xx] Media-based campaigns addressing perceptions of “social norms” have become prevalent, particularly among post-secondary institutions in the U.S., and also in Canada.[xxi]
One caution deserves note. When reviewing the broader literature on these social norm campaigns, Shultz and colleagues (2007) have found mixed results and suggest this may be because people measure the appropriateness of their behaviour by how far away they are from the norm – consequently students not using alcohol or drinking below the norm might see themselves as “deviant”. Although the majority of students do overestimate the prevalence of alcohol consumption, some actually underestimate its prevalence. So, normative information might have the unintended effect of inducing more alcohol use among those that had underestimated its prevalence.[xxii] The review by Shultz and colleagues focused on media-based campaigns, but it is possible this problem could arise with school instructional programs also. It is apparent that a good knowledge of students’ perceptions is important when using a social norms approach and that care be taken to construct a message that is health promoting for all students.[xxiii]
Competency Enhancement or Skills Training Model The second model that has been extensively studied and receives some support in the literature is the Competency Enhancement Model.[xxiv] This model emphasizes the teaching of personal and social skills either alone or in combination with elements of the social influence approach. These skills are taught using a combination of well-supported cognitive-behavioural skills training methods that can include instruction and demonstration, behavioural rehearsal (in-class practice), feedback and reinforcement, and out-of-class practice through behavioural homework assignments. The personal and social skills typically included in competence enhancement approaches are decision-making and problem-solving skills, cognitive skills for resisting peer and media influences, skills for increasing personal control and enhancing self esteem (e.g., goal-setting and self-directed behaviour change techniques), coping strategies for managing stress and anxiety, and assertive skills. This approach has been a common element in prevention programs to help young people address a number of issue areas (e.g., mental health, sexuality). Proponents of this approach however claim that the approach is only effective in reducing youth substance use if the skills practice and development are tied directly to drug-related situations or scenarios (rather than generic scenarios).[xxv] Historically, skills training programs have been held to be more effective than social influence programs.[xxvi] [xxvii]
However, Roona and colleagues (2000), in their meta-analysis of 128 interactive drug education programs, found that skills training approaches were no more effective than social influence programs, and at the middle school level were in fact, less effective. Also, the most visible of the competence enhancement programs, Botvin’s Life Skills Training (LST) program has been criticized by several reviewers on a number of grounds, including failing to report negative results on alcohol use, as well as for issues surrounding sample selection and attrition.[xxviii] [xxix] [xxx] [xxxi] A recent test of two delivery methods of the LST program by researchers independent of the program found neither method to be better than no program at all.[xxxii] Foxcroft (2003), employing the stringent standards of the Cochrane Collaboration, concluded that the evidence for long-term effectiveness (greater than 3 yrs) of the Life Skills Training (LST) program is not very convincing for alcohol prevention.[xxxiii] McGrath and colleagues (2006) suggested that the positive effects found with LST are mainly limited to legal substances and confined to students whose drug use is already low, and/or to those who received the complete program (hence likely to exclude those students already using drugs or those at most risk).[xxxiv] The meta-analysis by Tobler et al. (2000) found that adding life-skills training to social influence programs may strengthen the effects of prevention programs.[xxxv]
Best advice 5: at the junior/middle school level particularly, annually deliver universal substance education based on the Social Influences Model; this model can create a greater awareness of media and social influences, and help students develop skills to analyze and minimize their impact. Within this approach, accurate information that is free of moralizing needs to be available to students. Factors that may affect outcomes
Delivery methods The element of drug education programs with the strongest base of research support is student interactivity,[xxxvi] [xxxvii] [xxxviii] [xxxix] having been found to be 2-4 times more effective than non-interactive programs.[xl] Tobler and Stratton’s meta-analysis (1997) provided useful insight into the type of interactivity that is most effective. They found that programs emphasizing student-to-student, rather than student-to-teacher interaction, showed significantly more positive effects on student substance use. They assert that it is the structured and unstructured task-oriented peer interaction between classmates that is the important variable in effectiveness. In this process, students need to have the opportunity to interact in a small group context, to test out and exchange ideas on how to handle drug use situations and to gain peer feedback about the acceptability of their ideas in a safe environment. Tobler (2000) even goes so far as to suggest that it is the exchange of ideas and experiences between students, and the opportunity to practice new skills and to obtain feedback on skills practice that acts as a catalyst for change rather than any critical content of the program. The role of the teacher/leader in these types of sessions is to set an open, non-judgmental atmosphere, manage the process as a facilitator (rather than as a presenter), and maximize the opportunity for peer interchange and skills practice. The teacher also plays an important role in correcting misperceptions that may arise, and in offering information as needed.[xli] The specific techniques that work well in this process are role-plays, Socratic questioning, simulations, brainstorming, cooperative learning, peer-to-peer discussion and service-learning projects.
Best advice 6: universal substance education needs to emphasize student-to-student, rather than student-to-teacher, interactivity; this may involve role-plays, Socratic questioning, simulations, brainstorming, cooperative learning, peer-to-peer discussion and service-learning projects.
Teacher/leader qualities While most evaluated programs have been led by trained teachers, many others, particularly peers, have also led programs. Gottfredson and Wilson (2003), in their meta-analysis of 94 drug education programs, found programs that were led by peers unassisted by teachers to be clearly more effective than teacher-led programs or programs co-led by teachers and peer leaders.[xlii] A common role for peer leaders is to lead the normative component of the program to enhance the believability of normative information on drug use.[xliii] Often peer leaders gain greater benefit than classroom students from peer led programs.[xliv] Cautions have been identified in using peer leaders, particularly the need for careful selection and training of appropriate leaders.[xlv] [xlvi] Peer programs also require more planning. Practical considerations include timetabling, peer training, peer leader absence, length of time between peer leader training and their use in the classroom, and any additional funding required to conduct such programs.[xlvii] The Tobler et al 1998 meta-analysis found mental health practitioners and peer leaders were superior to general classroom teachers, but not significantly.[xlviii] It is often concluded that drug education is best taught by classroom teachers due to: the challenges of sustaining a peer-led program; their having first-hand knowledge of students' needs and developmental level, andbeing best placed to deliver (and if necessary to modify) program components at an appropriate time and level for their students.[xlix] The question of who delivers is quite possibly secondary to the question of what qualities are important for the person who delivers. It is speculated that mental health practitioners are effective because they have skills and training in facilitation and group process, for example creating a non-judgmental atmosphere, being comfortable in a non-directive role (e.g., with ambivalence, and with remaining silent to facilitate dialogue). Regardless of who is delivering, best results can be expected from selecting teacher/leaders with these qualities, acquired through some mix of personal attributes and pre- or in-service training.[l] Guest presenters are often considered for drug education sessions. Given this evidence, it is important that guest presenters be able to address curriculum objectives and work interactively with the students, rather than present an isolated session unconnected with the curriculum.[li] Newer interactive technologies (e.g., CD-ROM, DVD, Internet) to present or reinforce relevant knowledge and skills may be a useful adjunct to classroom prevention programs.[lii]
Best advice 7: classroom lessons are best led by teachers or leaders that are comfortable with and have competence in promoting interactivity among students on substance use issues. Teachers / leaders need to create a non-judgmental atmosphere in order to effectively lead these activities.
Timing of program
Elementary school While relatively few in number, elementary school programs (for children aged 6-12 years) aiming to prevent later substance use do exist and a few have been evaluated. A challenge for these programs is the length of time required for follow-up in order to show results. When asked, teachers suggested that early elementary school drug education is best suited to address the safe handling of medication and alternatives to medication and that drug issues are best placed within much broader questions such as “how do I make healthy decisions about life” and “how do I make decisions about my health”.[liii] Overall, there is little evidence supporting the effectiveness of drug education curriculum at the elementary level.[liv] [lv] [lvi] The limited literature available suggests that elementary school interventions should focus more so on fundamental risk factors and devote attention to family/parent programming, school organisation and behavioural management.[lvii] (See the sections on Targeted and Comprehensive Whole School Approaches).
Middle/Junior High School Most drug education programs and evaluations are directed to middle/junior high school students. Gottredson and Wilson (2003) found that programs directed to this population were more effective than those directed to younger and older students, but that the effects were weak in all cases.[lviii] [lix] The meta-analysis by Roona et al (2000) found that the most effective method at this level was the social influence model.[lx] Senior High School Another approach to determining timing of programming is to base the decision on local student drug use data. McBride (2003) has put forward a three-stage approach that is based on students' behavioural development and use patterns.[lxi] No evidence was found on the value of this approach but it is based on data and theory. The suggested age ranges presented here are based on the general Canadian picture (if there is reason to believe that the situation differs in a particular school or region, the curriculum should be adjusted accordingly).
According to this approach, the first stage of drug education is inoculation, which should occur prior to the average age of first use of a substance but when interest in the substance is occurring (e.g., for alcohol, about age 11-12 years or Grade 5-6). Early relevance, when most students are experiencing initial exposure and some are experimenting with the substance is the second stage (e.g., for alcohol about 13-14 years of age or Grade 7-8). An increasing number of students are beginning to use alcohol at this time, so providing relevant interactive opportunities to engage on issues relevant to them is likely to have meaning and practical value. The third and final stage is later relevance. The later relevance stage should be delivered at a point when students are exposed to higher risk forms of use, different situations, and/or different substances (e.g., alcohol, 15-17 years of age or Grade 9-11). Later relevance messages need to account for the level and pattern of use (for example, an alcohol abstinence message in a class where 60-70% of the students have used in the past year, and a quarter to a third have been drunk, will likely not be taken seriously by many). Recognizing that those students who choose not to use need to be supported in that decision, strategies for promoting safety and minimizing hazardous patterns of use also need to be considered for relevant substances at this point.[lxii] Programs can be best tailored to a population by using local prevalence data.[lxiii] [lxiv] It is likewise important to have some insight into local youth culture, which tends to evolve rapidly.[lxv] This represents an impossible challenge to most adults so it is best accomplished through activities that allow students to create their own ‘real world’ scenarios.[lxvi] Doing this builds in a flexibility that allows the targeting of drug issues as they arise or become pertinent, and the delivery of sessions that engage students with real, rather than abstract, scenarios.
Program length Does the number of program hours have a bearing on effectiveness? In the literature this question is often discussed in terms of duration (e.g. number of weeks it takes to deliver the program) and intensity (e.g. hours per session and sessions per week). It has been commonly accepted that when it comes to program effectiveness, more program hours is better.[lxvii] [lxviii] [lxix] For example, McBride suggests that 10 or more sessions per year through junior high school is preferable but if that is not possible, to follow the initial 10-session module with 4-8 sessions, followed by 3-8 second boosters and, if prevalence indicates, 3-5 third boosters in each subsequent year.[lxx] White and Pitt (1998) in their review of programs focusing on illicit drugs found that 80% of effective programs had 10 or more sessions.[lxxi] However, Cuiper 2002 concluded that there is no definite evidence that intense programs are more effective than less intense programs.[lxxii] Gottfredson and Wilson (2003) found no difference in effectiveness between programs longer than 4.5 months duration and those shorter, but they acknowledged that duration may be a poor proxy for number of contact hours. [lxxiii] [lxxiv]
While it remains clear that ‘one-offs’ or occasional presentations have no measurable effect on behaviours,[lxxv] [lxxvi] the research on this question is not clear, and it may be in part due to confusion around the terms “intensity” and “duration”. Evidence concerning booster sessions (i.e. shorter programs [3-5 sessions] offered in succeeding years to reinforce concepts and skills) is similarly mixed. Skara and Sussman (2003) found that programs using booster sessions were less likely to decay over the longer term (2 or more years), [lxxvii] while Gottfredson and Wilson (2003) found no evidence that booster sessions improved outcomes.[lxxviii] It may seem counterintuitive that a shorter program can be as effective as a longer one, but brief interventions (1-6 sessions) have been found effective with various higher risk populations (See Section IV C, Targeted Curriculum and Services for Higher Risk Students). While awaiting research to provide more clarity on this, decisions around program length are best driven by the particular aims of a program, bearing in mind that recommended interactive programs tend to require more time to process than lecture-based programs.
Delivering program as designed The extent to which Canadian schools or boards use evidence-based drug education curriculum is unknown and it is not known how fully teachers implement the programs they do use. Across the U.S., Rorbach and colleagues (2005) found that less than half the school districts (i.e. boards) reported using evidence-based curriculum in at least one middle school.[lxxix] How a particular program is identified for use in a district is an important question, with this same study finding that district drug coordinators had the most influence, followed by principals and teachers. A number of drug education-related studies have shown that programs are more likely to have a significant impact on key outcomes when they are delivered as intended.[lxxx] This is referred to as delivering the program with “fidelity” and it has been measured in five ways: (1) adherence to the program; (2) the amount delivered; (3) quality of program delivery; (4) participant responsiveness; and (5) program differentiation [extent to which key elements are present].
A survey of a national sample of U.S. middle school drug educators found that most of these teachers reported presenting the content as designed but fewer than 1 in 5 reported that they used interactive teaching methods more often than non-interactive methods, and only 14% implemented both content and process as designed.[lxxxi] Similarly when Sobeck and colleagues (2006) checked teachers' logs in a local survey, they found that interactive lessons were least likely to be used.[lxxxii] The extent to which teacher deviation or adaptation should be discouraged has been debated, with some contending that any “program drift” will diminish outcomes and others arguing that some adaptation to meet local needs is often acceptable and necessary.[lxxxiii] However, if the most common adaptation or deviation is to deliver interactive programs in a didactic manner, outcomes are undoubtedly being affected and this should be viewed as a serious problem. See Section V. G., Factors Affecting Program Implementation in the Real World, for discussion on implementation and capacity issues.
Conclusion A challenge for universal curriculum-based programs is in arriving at a successful “one size fits all” program.[lxxxiv] Universal programs are unable to tailor their content for minority groups or for higher risk youth who may be in those classes. Therefore, the intensity, dosage, content and method of delivery may not match particular needs. It appears that universal programs are more effective with lower-risk students. Nevertheless, the literature points to modest, short-term effects for universal classroom substance education programs. Evidence-based interactive programs directed to middle/junior high school students have shown more promise than other levels. They can be expected to delay or prevent onset of use, hazardous use and harmful consequences among some of the students exposed to the programming. This modest effectiveness can translate into a sizable public health benefit with broadly delivered programs. Caulkins (2002) estimated that for every $US150 per participant in a school program (he based the analysis on Project ALERT) $US840 is saved in health care, economic, and social costs.[lxxxv] This figure takes into account that the studied program, as is the case for even the more effective programs, is not able to sustain its effects beyond a year or two. (For more information on cost effectiveness of this and other models, see Section V. F. Cost Effectiveness in Preventing Substance Use Problems through Schools).
Indeed, to put the effectiveness of school drug education into perspective, Tobler and Stratton (1997) note that the average effect size of interactive programs (averaging 10 hours duration) at 0.2 compares favourably to effectiveness trials in the medical field, where for example it was deemed unethical to withhold the release of aspirin because of its effect size of 0.035.[lxxxvi] So, universal junior high school curriculum-based programs have the potential to provide an important contribution to the prevention of adolescent substance use problems. The evidence is weaker for elementary and senior high school curriculum-based programs. But even with active and widespread dissemination of evidence-based programs and guidelines in the U.S., research in that country has shown that the use of evidence-based school drug education programs is not common in that country. Moreover, the evidence-based programs in use in the U.S. are often not being delivered as intended. The situation in Canada isn’t known but doesn’t likely differ greatly. B. Universal curriculum with aims other than abstinence Over the past 10 years, some researchers have increasingly advocated for the implementation and testing of school drug education programs that include attention to outcomes other than abstinence from substances.[lxxxvii] [lxxxviii] [lxxxix] This is based on the fact that a significant percentage of students in Western societies use alcohol and other substances (particularly cannabis) in the later high school years, often in risky ways. However current school programs often do not reflect this reality. In this context, a program that promotes abstinence as the only viable option may not be taken seriously by students.[xc] [xci] Even though official U.S. drug policy does not support outcomes to interventions other than abstinence, a U.S. review has expressed support for this approach. As a result of their meta-analysis, Roona and colleagues (2000) concluded that “promoting abstinence may not be a viable objective when substance use is normative in the culture, but preventing abuse and its attendant harms may be viable” (p. 20).[xcii] Since a mistake or poor choice can result in drug-related harm or even death, high school students need to be encouraged to avoid hazardous patterns of use common in that population, and when hazardous use has occurred, to avoid harms. By neglecting to give attention to risky patterns or situations and how to avoid them or to minimize harms associated with them, a program misses an important opportunity to provide practical – possibly lifesaving – instruction on this issue.[xciii] This message is best presented alongside a message that identifies abstinence as the most promising option for avoiding risks and harms.
McBride suggests replacing resistance skills training (which has been shown to be based on faulty assumptions) with skills training to help youth reduce hazardous use patterns and harms when they do occur.[xciv] There is limited information on when to introduce these types of aims and messages, but the decision is best made on the basis of the consumption patterns in a region – the most relevant information being the prevalence of hazardous patterns (e.g., binge drinking, drunkenness, use of more than one substance, and use in risky situations such as before driving), however, the prevalence of past year use of a substance is also relevant (this may be the only information available for cannabis and other illegal substances). Each school board and health district needs to make its own determination on when, based on local data, it is necessary to focus on reducing hazardous patterns of use.
For example, if in Nova Scotia (based on 2002 data) a rate of 50% or more of students having used alcohol or 25% having gotten drunk in the past year were seen as benchmarks, then a focus on reducing patterns of hazardous alcohol use would begin in Grade 9. This type of safety-oriented instruction should be provided within an overall message emphasizing abstinence as the safest option. This has been referred to as “harm reduction” education and it has been controversial, with some stakeholders feeling uneasy about the approach. Research in Nova Scotia found that harm reduction messaging was viewed by stakeholders (i.e. parents, health officials, school personnel, and students) in 1998-2002 as acceptable with senior high school populations and not acceptable at the junior high level (with less clarity around Grade 9 appropriateness).[xcv]
A common concern around use of this strategy with younger students was that they didn’t have the capacity to make informed decisions concerning the context of substance use. This study didn’t distinguish between substances in discussions around acceptability. The use of the term harm reduction for this kind of instruction is a red flag for some, and in some cases, may not even be a fully accurate term; much of it would be more accurately termed hazardous use reduction or simply demand reduction. According to definitions proposed by Stockwell (2006), harm reduction best refers to programs or policies that do not necessarily call for reduced consumption or a change in consumption pattern on the part of the user.[1] Accordingly, instruction aiming to delay the onset of use, or reduce the frequency of use, the amount used or other hazardous use by students would all be considered “demand reduction”. The following are examples of hazardous use prevention or harm reduction messages relevant to adolescent populations, noting there is no research evidence to support their use at this point:
Hazardous use prevention:
Harm reduction:
Likewise, McBride and Farrington (2004) reported lower levels of total and risky consumption of alcohol, and lower levels of harms associated with alcohol use in their evaluation of what they termed a harm reduction-oriented program (but which would more precisely be considered a mix of demand reduction/hazardous use prevention and harm reduction) for 13- to 16-year-old students in Australia.[c] Rather than focusing on skills to resist pressure to use, the School Alcohol Harm Reduction Program (SHAHRP) gave attention to skills to reduce risk and to reduce the impact of the harm. The intervention was conducted in two phases over a 2-year period. The initial phase was implemented during the first year of secondary school when the majority of students were 13 years of age. It consisted of 17 skill-based activities conducted over eight to ten lessons (depending on lesson length of either 40 or 60 minutes).
Phase 2 was conducted in the following year when the students were 14 years of age. It consisted of 12 activities delivered over 5–7 weeks. The program activities incorporated various strategies for interactive dissemination including delivery of utility information; skill rehearsal; individual and small group decision making; and discussions based on scenarios suggested by students, with an emphasis on identifying alcohol-related harm and strategies to reduce harm. The program allowed students to discuss and practice behaviours in a low-risk situation, using real-life scenarios, giving them relevant skills they could take with them into actual situations. The authors reported that the results of this approach show behavioural change equal to or greater than programs that have adopted a resistance skills training approach. At 15 months following program completion, differences between intervention and comparison students were beginning to converge; nevertheless at that point students who participated in the program consumed 9% less alcohol, were 4.2% less likely to consume to hazardous levels, experienced 23% less harm from their own use of alcohol and 13% less harm from others’ use of alcohol than did the comparison group.[ci]
These are encouraging results and call for more investigation of the effectiveness of school-based programming aiming to reduce hazardous use and possible harms among students. While the rationale is sound and the few findings are promising, it has been argued that the bar for evidence needs to be set particularly high for school programming that accepts youth activity that falls outside the law. As noted by Poulin (2005), school administrators have a duty of care to under-aged youth through the law and formal policy.[cii] It could be argued that well-based hazardous use prevention and harm reduction programming is in fact an important contribution to a school’s duty of care responsibilities; nevertheless, that contention needs to be supported by more research to fully demonstrate the effectiveness of school prevention programs that include hazardous use prevention or harm reduction elements. In the meantime, schools and communities need to continue to seek acceptable responses to widespread hazardous use of alcohol and to a lesser extent other substances by young people in this country.
End Notes
[1] In an attempt to reduce the confusion still surrounding these terms, Stockwell (2006) has proposed a breakdown drawn from a public health perspective which recognizes the need to address the agent (through supply reduction), the individual (through demand reduction) and the environmental context (harm reduction). · Supply reduction: strategies that are intended to achieve social, health, and safety benefits by reducing the physical availability of a particular substance. · Demand reduction: strategies which succeed by motivating users to consume less overall and/or less per occasion, but don’t necessarily call for abstinence. · Harm reduction: strategies that reduce the likelihood of harm to health and safety without necessarily requiring a change in the pattern or level of substance use.
[i] McBride, N. (2004). School drug education: A developing field and one element in a community approach to drugs and young people: A response to the commentaries. Addiction, 99(3), 296.
[ii] Flay, B.R. (2000). Approaches to substance use prevention utilizing school curriculum plus social environment change. Addictive Behaviors, 25(6), 861-885.
[iii] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023.
[iv] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[v] Flay, B.R., & Petraitis, J. (1994). The theory of triadic influence. A new theory of health behavior with implications for preventative interventions. Advances in Medical Sociology, 4, 19-44.
[vi] Botvin, G. J. (2000). Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors, 25(6), 887-897.
[vii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[viii] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50.
[ix] Allott, R., Paxton, R., & Leonard, R. (1999). Drug education: A review of British government policy and evidence on effectiveness. Health Education Research: Theory & Practice, 14(4), 491-505.
[x] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50.
[xi] Allen & Clarke Policy and Regulatory Specialists Ltd. (2003). Effective drug education for young people: Literature review and analysis. Retrieved August 31, 2007, from http://www.myd.govt.nz/uploads/docs/0.7.1.1%20effective%20drug%20ed.pdf
[xii] Sheppard, M.A., Wright, D., & Goodstadt, M.S. (1985). Drug use and peer pressure: Exploding the myth. Adolescence, 20(80), 949-958.
[xiii] Botvin, G. J. (2000). Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors, 25(6), 887-897.
[xiv] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023.
[xv] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[xvi] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023. [xvii] Hansen, W., & Graham, J. (1991). Preventing alcohol, marijuana, and cigarette use among adolescents: Peer pressure resistance training versus establishing conservative norms. Preventive Medicine, 20(3), 414-430.
[xviii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[xix] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[xx] Agostinelli, G. & Grube, J. (2002). Alcohol counter-advertising and the media: A review of recent research. Alcohol Research and Health, 26(1), 15-21.
[xxi] Perkins, H., Haines, M., and Rice, R. (2005). Misperceiving the college drinking norm and related problems: A nationwide study of exposure to prevention information, perceived norms and student alcohol misuse. Journal of Studies on Alcohol, 66, 470-478.
[xxii] Schultz, W., Nolan, J., Cialdini, R., Goldstein, N., Griskevicius, V. (2007). The Constructive, Destructive, and Reconstructive Power of Social Norms. Psychological science, 18(5).
[xxiii] Granfield, R. (2004). Alcohol use in college: Limitations on the transformation of social norms. Addiction Research and Theory, 13(3), 281–292.
[xxiv] Botvin, G. J. (2000). Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors, 25(6), 887-897.
[xxv] ibid
[xxvi] Tobler, N.S., & Stratton, H.H. (1997). Effectiveness of school-based drug prevention programs: A meta-analysis of the research. The Journal of Primary Prevention, 18(1), 71-128.
[xxvii] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[xxviii] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50.
[xxix] Coggans, N., Cheyne, B., & McKellat, S. (2002). The life skills training drug education programme: A review of research. Retrieved August 31, 2007, from http://www.drugmisuse.isdscotland.org/eiu/pdfs/eiu_lifeskl.pdf
[xxx] Foxcroft, D., Ireland, D.J., Lister-Sharp, D., Lowe, G., & Breen, R. (2003). Longer-term primary prevention for alcohol misuse in young people: A systematic review. Addiction, 98, 397-411.
[xxxi] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf
[xxxii] Vicary, J.R., Smith, E.A., Swisher, J.D., Bechtel, L.J., Elek, E., Henry, K.L., et al. (2006). Results of a 3-year study of two methods of delivery of life skills training. Health education behavior, 33(3), 325-339.
[xxxiii] Foxcroft, D., Ireland, D.J., Lister-Sharp, D., Lowe, G., & Breen, R. (2003). Longer-term primary prevention for alcohol misuse in young people: A systematic review. Addiction, 98, 397-411.
[xxxiv] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf
[xxxv] Tobler, N.S. (2000). Lessons learned. The Journal of Primary Prevention, 20(4), 261-274.
[xxxvi] Tobler, N.S., & Stratton, H.H. (1997). Effectiveness of school-based drug prevention programs: A meta-analysis of the research. The Journal of Primary Prevention, 18(1), 71-128.
[xxxvii] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023.
[xxxviii] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf
[xxxix] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[xl] Tobler, N.S., & Stratton, H.H. (1997). Effectiveness of school-based drug prevention programs: A meta-analysis of the research. The Journal of Primary Prevention, 18(1), 71-128.
[xli] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[xlii] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38.
[xliii] Skara, S., & Sussman, S. (2003). A review of 25 long-term adolescent tobacco and other drug use prevention program evaluations. Preventive Medicine, 37, 451-474.
[xliv] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[xlv] Loxley, W., Toumbourou, J.W., & Stockwell, T. (2004). The prevention of substance use, risk and harm in Australia: A review of the evidence. Retrieved September 30, 2007, from http://www.aodgp.gov.au/internet/wcms/publishing.nsf/content/health-pubhlth-publicat-document-mono_prevention-cnt.htm
[xlvi] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf
[xlvii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742. [xlviii] Tobler, N.S. (2000). Lessons learned. The Journal of Primary Prevention, 20(4), 261-274.
[xlix] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[l] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf
[li] Buckley, E.J., & White, D.G. (2007). Systematic review of the role of external contributors in school substance use education. Health Education, 107(1), 42-62.
[lii] Williams, C., Griffin, K.W., Macaulay, A.P., West, T.L., & Gronewold, E. (2005). Efficacy of a drug prevention CD-ROM intervention for adolescents. Substance Use and Misuse, 40(6), 869-878.
[liii] Godfrey, C., Toumbourou, J.W., Rowland, B., Hemphill, S., Munro, G., & Farrell, C. (2002). Drug education approaches in primary schools [Prevention research evaluation report No. 4]. Retrieved September 30, 2007, from http://www.druginfo.adf.org.au/download.asp?RelatedLinkID=578
[liv] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38.
[lv] Godfrey, C., Toumbourou, J.W., Rowland, B., Hemphill, S., Munro, G., & Farrell, C. (2002). Drug education approaches in primary schools [Prevention research evaluation report No. 4]. Retrieved September 30, 2007, from http://www.druginfo.adf.org.au/download.asp?RelatedLinkID=578
[lvi] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf
[lvii] Godfrey, C., Toumbourou, J.W., Rowland, B., Hemphill, S., Munro, G., & Farrell, C. (2002). Drug education approaches in primary schools [Prevention research evaluation report No. 4]. Retrieved September 30, 2007, from http://www.druginfo.adf.org.au/download.asp?RelatedLinkID=578
[lviii] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38.
[lix] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf
[lx] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf [lxi] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742. [lxii] ibid [lxiii] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf [lxiv] White, D., & Pitts, M. (1998). Educating young people about drugs: A systematic review. Addiction, 93(10), 1475-1487. [lxv] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50. [lxvi] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf [lxvii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742. [lxviii] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38. [lxix] White, D., & Pitts, M. (1998). Educating young people about drugs: A systematic review. Addiction, 93(10), 1475-1487. [lxx] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742. [lxxi] White, D., & Pitts, M. (1998). Educating young people about drugs: A systematic review. Addiction, 93(10), 1475-1487 [lxxii] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023. [lxxiii] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38. [lxxiv] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf [lxxv] Dusenbury, L., Falco, M., & Lake, A. (1997). A review of the evaluation of 47 drug abuse prevention curricula available nationally. Journal of School Health, 67(4), 127-132. [lxxvi] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Geneva, Switzerland: World Health Organization. [lxxvii] Skara, S., & Sussman, S. (2003). A review of 25 long-term adolescent tobacco and other drug use prevention program evaluations. Preventive Medicine, 37, 451-474. [lxxviii] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38. [lxxix] Rohrbach, L.A., Ringwalt, C.L., Ennett, S.T., & Vincus, A.A. (2005). Factors associated with adoption of evidence-based substance use prevention curricula in US school districts. Health Education Research, 20(5), 514-526. [lxxx] Dusenbury, L., Brannigan, R., Falco, M., & Hansen, W.B. (2003). A review of research on fidelity of implementation: Implications for drug abuse prevention in school settings. Health Education Research: Theory and Practice, 18(2), 237-256. [lxxxi] Ennett, S.T., Ringwalt, C. L., Thorne, J., Rohrbach, L.A., Vincus, A., Simons-Rudolph, A., & Jones, S. (2003). A comparison of current practice in school-based substance use prevention programs with meta-analysis findings. Prevention Science, 4(1), 1-14. [lxxxii] Sobeck, J.L., Abbey, A., & Agius, E. (2006). Lessons learned from implementing school-based substance abuse prevention curriculum. Children & Schools, 28(2). [lxxxiii] Ringwalt, C.L., Ennett, S., Johnson, R., Rohrbach, L.A., Simons-Rudolph, A., Vincus, A., & Thorne, J. (2003). Factors associated with fidelity to substance use prevention. Curriculum guides in the nation’s middle schools. Health Education & Behavior, 30(3), 375-391. [lxxxiv] Allen & Clarke Policy and Regulatory Specialists Ltd. (2003). Effective drug education for young people: Literature review and analysis. Retrieved August 31, 2007, from http://www.myd.govt.nz/uploads/docs/0.7.1.1%20effective%20drug%20ed.pdf [lxxxv] Caulkins, J.P. (2002). School-based drug prevention: What kind of drug use does it prevent? Retrieved August 31, 2007, from http://www.rand.org/pubs/monograph_reports/2007/MR1459.pdf [lxxxvi] Tobler, N.S., & Stratton, H.H. (1997). Effectiveness of school-based drug prevention programs: A meta-analysis of the research. The Journal of Primary Prevention, 18(1), 71-128. [lxxxvii] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf [lxxxviii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742. [lxxxix] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf [xc] Rosembaum, M. (2002). Safety first: A reality-based approach to teens, drugs, and drug education. Retrieved August 31, 2007, from http://www.safety1st.org/images/stories/pdf/safetyfirst.pdf [xci] Kay, J. (1994). Don’t wait until it’s too late. International Journal of Drug Policy, 5(3), 166-175. [xcii] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf [xciii] Rosembaum, M. (2002). Safety first: A reality-based approach to teens, drugs, and drug education. Retrieved August 31, 2007, from http://www.safety1st.org/images/stories/pdf/safetyfirst.pdf [xciv] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742. [xcv] Poulin, C., & Nicholson, J. (2005). Should harm minimization as an approach to adolescent substance use be embraced by junior and senior high schools? Empirical evidence from an integrated school and community-based demonstration intervention addressing drug use among adolescents. International Journal of Drug Policy, 16, 403–414. [xcvi] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50. [xcvii] Brounstein, P., Gardner, S.E., & Backe, T.E. (2006). Research to Practice: Efforts to Bring Effective Prevention to Every Community. The Journal of Primary Prevention, 27(1). [xcviii] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf [xcix] Poulin, C., & Nicholson, J. (2005). Should harm minimization as an approach to adolescent substance use be embraced by junior and senior high schools? Empirical evidence from an integrated school and community-based demonstration intervention addressing drug use among adolescents. International Journal of Drug Policy, 16, 403–414. [c] McBride, N., Farringdon, F., Midford, R., Meuleners, L., & Phillips, M. (2004). Harm minimization in school drug education: Final results of the school health and alcohol harm reduction project (SHAHRP). Addiction, 99(3), 278-291. [ci] ibid [cii] Poulin, C. (2006). Harm reduction policies and programs for youth. Harm reduction for special populations in Canada #2. Retrieved September 12, 2007, from http://www.ccsa.ca/NR/rdonlyres/D0254373-5F2B-459D-BB79-6EE7C22CC303/0/ccsa113402006.pdf
An excerpt from, "School-based and school-linked prevention of substance use problems: A knowledge summary", Canadian Association for School Health, 2008.
The vast majority of the student substance abuse prevention programs that have been evaluated are universal curriculum-based programs. The benefits of even the most effective of these drug education programs tend to erode. Studies show that groups that receive what is usually a 10-session program are generally found to be using substances at a similar rate to comparison groups one or two years following the completion of the program. Some observers see this as a failure of drug education, while others suggest that it is not surprising that the effects do not last too long considering the various influences at play in the lives of youth.[i] They contend that even a delay in use or reduced use over one or two adolescent years is an important contribution during a period when use can be particularly risky and prevalence rates escalate quickly. Seen in this light, the erosion effect simply highlights the need for yearly attention to the issue in the classroom and ongoing research to better understand the most effective components of these programs. Many of the factors that can influence youthful substance use lie beyond the school grounds. When attempting to support young people in navigating through adolescence with a minimum of substance-related harm, educators and community members are up against major societal forces. Among the many individual, social, and cultural factors that can come into play as a young person makes his or her way to adulthood, teachers are in a position to influence only a few of these factors through curriculum and instruction.[ii] The opportunities lie in the realm of understanding and coping effectively with social influences that promote substance use, and supporting the development of pertinent personal and social skills (e.g., assertiveness, decision-making and stress management).[iii] [iv]
Social influence programs The Social Influences Model views adolescent use of substances to be the result of influences from family, peers and the media.[v] These influences may be in the form of substance use by family, peers and media personalities or messages condoning or encouraging use. This model aims to create greater awareness of the various influences, and to help students develop skills to analyze and minimize their impact on their substance use. In their earliest forms, social influence programs included a component referred to as psychological inoculation, which exposed students to increasingly persuasive pro-drug messages as a way of inoculating them or building resistance to real-life drug-related messages. Studies have not shown inoculation to contribute to the effectiveness of drug education, so more recent program designs do not include this element.[vi]
An element of social influence programs that continues to be popular is resistance skills training. This element is based on the assumption that adolescents begin to use substances largely because they lack the confidence or skills to resist social influences to smoke, drink, or use other drugs. Therefore, this approach focuses on identifying instances when these types of influences are at play. Emphasis is often placed on teaching students to identify the techniques used by advertisers to influence consumer behaviour. Once these instances and messages are recognized and identified, students can be taught tactics for dealing with the messages. For example, students may be made more aware of advertising designed to sell tobacco products or alcoholic beverages and given the chance to formulate counter-arguments. Similarly, they learn about various situations involving peer influence, and develop a repertoire of responses to the influences. Attention is paid to the content of responses, their tone, and accompanying body language.[vii] Resistance skills training is controversial in the research community in that some continue to advocate its use while others contend that a portion of it is based on a faulty assumption.[viii] [ix] The evidence indicates that peer pressure has been exaggerated as a causal factor in risk behaviours. First of all, anyone who begins to use a substance, including young people, does so for a variety of reasons, and to fulfill a range of needs. The influence is often nuanced and might be better termed ‘peer preference,’ or ‘peer selection’ with a young person picking a peer group on the basis of its preferences on a number of fronts, such as music, clothing, use of substances, or social justice concerns.[x] While they may not have been pressured into using by peers, they may be pressured not to quit, or to drink or use at a certain level.[xi] [xii] A common element of this approach for which there is no scientific evidence is making a public commitment not to smoke, drink, and/or use other substances.[xiii] Cuipers (2002) concluded that research has not found resistance skills training to contribute to the effectiveness of programs.[xiv] In their meta-analysis, Roona et al. (2000) found that interactive middle school drug education programs that did not teach refusal skills were just as effective as interactive middle school programs that did so.[xv]
An element in social influence programming that is better supported by scientific evidence is normative education. [xvi] [xvii] It is commonly accepted that young people tend to overestimate the prevalence of smoking, drinking, and other drug use among other adolescents and adults. This leads to an inaccurate sense of how ‘normal,’ or accepted alcohol and other drug use is in a young person’s school, neighbourhood, or community. Normative approaches are designed to correct the misperception that ‘everyone is doing it.’ A method that has been used to modify or correct normative expectations involves providing students with information about the prevalence of drug use from national or local surveys. Since the actual rates of substance use in most classes, schools, and communities is consistently quite a bit lower than adolescents believe, this activity helps correct misperceptions and shift norms. However, this approach can obviously only work with substances and student populations where the percentage of users is in fact relatively low (for example, less than 40% of students using in the past year).[xviii] Because rates of use for common substances increase rapidly through the middle/high school years, it is important that age-specific data be used for these purposes. Using the 40% benchmark with Ontario students (because of the availability of recent data), normative education would have been appropriate in 2007 for alcohol in Grades 7 and 8, cannabis in Grades 7-10 and tobacco in Grades 7-12.
The logic of a normative approach also applies to hazardous use (rather than any use per se). Norms around hazardous behaviours, such as binge drinking or riding with someone who is impaired, could also be the focus of normative education, if supporting data are available. There is some evidence from a meta-analysis that normative education is effective in reducing incidents of heavy drinking at the junior high school level.[xix] More recently, Agostinelli and Grube (2002) tested two versions of a normative approach against a control in a randomized sample of older high school students in the U.S. With one version, students were provided with information about student drinking patterns in their locale; in the second, students received this information along with personalized information comparing their own drinking patterns against the norm, while the control students received neither. Both approaches were effective in reducing the tendency to underestimate the number of students who did not engage in heavy drinking, but only the personalized approach resulted in students adopting more conservative personal standards.[xx] Media-based campaigns addressing perceptions of “social norms” have become prevalent, particularly among post-secondary institutions in the U.S., and also in Canada.[xxi]
One caution deserves note. When reviewing the broader literature on these social norm campaigns, Shultz and colleagues (2007) have found mixed results and suggest this may be because people measure the appropriateness of their behaviour by how far away they are from the norm – consequently students not using alcohol or drinking below the norm might see themselves as “deviant”. Although the majority of students do overestimate the prevalence of alcohol consumption, some actually underestimate its prevalence. So, normative information might have the unintended effect of inducing more alcohol use among those that had underestimated its prevalence.[xxii] The review by Shultz and colleagues focused on media-based campaigns, but it is possible this problem could arise with school instructional programs also. It is apparent that a good knowledge of students’ perceptions is important when using a social norms approach and that care be taken to construct a message that is health promoting for all students.[xxiii]
Competency Enhancement or Skills Training Model The second model that has been extensively studied and receives some support in the literature is the Competency Enhancement Model.[xxiv] This model emphasizes the teaching of personal and social skills either alone or in combination with elements of the social influence approach. These skills are taught using a combination of well-supported cognitive-behavioural skills training methods that can include instruction and demonstration, behavioural rehearsal (in-class practice), feedback and reinforcement, and out-of-class practice through behavioural homework assignments. The personal and social skills typically included in competence enhancement approaches are decision-making and problem-solving skills, cognitive skills for resisting peer and media influences, skills for increasing personal control and enhancing self esteem (e.g., goal-setting and self-directed behaviour change techniques), coping strategies for managing stress and anxiety, and assertive skills. This approach has been a common element in prevention programs to help young people address a number of issue areas (e.g., mental health, sexuality). Proponents of this approach however claim that the approach is only effective in reducing youth substance use if the skills practice and development are tied directly to drug-related situations or scenarios (rather than generic scenarios).[xxv] Historically, skills training programs have been held to be more effective than social influence programs.[xxvi] [xxvii]
However, Roona and colleagues (2000), in their meta-analysis of 128 interactive drug education programs, found that skills training approaches were no more effective than social influence programs, and at the middle school level were in fact, less effective. Also, the most visible of the competence enhancement programs, Botvin’s Life Skills Training (LST) program has been criticized by several reviewers on a number of grounds, including failing to report negative results on alcohol use, as well as for issues surrounding sample selection and attrition.[xxviii] [xxix] [xxx] [xxxi] A recent test of two delivery methods of the LST program by researchers independent of the program found neither method to be better than no program at all.[xxxii] Foxcroft (2003), employing the stringent standards of the Cochrane Collaboration, concluded that the evidence for long-term effectiveness (greater than 3 yrs) of the Life Skills Training (LST) program is not very convincing for alcohol prevention.[xxxiii] McGrath and colleagues (2006) suggested that the positive effects found with LST are mainly limited to legal substances and confined to students whose drug use is already low, and/or to those who received the complete program (hence likely to exclude those students already using drugs or those at most risk).[xxxiv] The meta-analysis by Tobler et al. (2000) found that adding life-skills training to social influence programs may strengthen the effects of prevention programs.[xxxv]
Best advice 5: at the junior/middle school level particularly, annually deliver universal substance education based on the Social Influences Model; this model can create a greater awareness of media and social influences, and help students develop skills to analyze and minimize their impact. Within this approach, accurate information that is free of moralizing needs to be available to students. Factors that may affect outcomes
Delivery methods The element of drug education programs with the strongest base of research support is student interactivity,[xxxvi] [xxxvii] [xxxviii] [xxxix] having been found to be 2-4 times more effective than non-interactive programs.[xl] Tobler and Stratton’s meta-analysis (1997) provided useful insight into the type of interactivity that is most effective. They found that programs emphasizing student-to-student, rather than student-to-teacher interaction, showed significantly more positive effects on student substance use. They assert that it is the structured and unstructured task-oriented peer interaction between classmates that is the important variable in effectiveness. In this process, students need to have the opportunity to interact in a small group context, to test out and exchange ideas on how to handle drug use situations and to gain peer feedback about the acceptability of their ideas in a safe environment. Tobler (2000) even goes so far as to suggest that it is the exchange of ideas and experiences between students, and the opportunity to practice new skills and to obtain feedback on skills practice that acts as a catalyst for change rather than any critical content of the program. The role of the teacher/leader in these types of sessions is to set an open, non-judgmental atmosphere, manage the process as a facilitator (rather than as a presenter), and maximize the opportunity for peer interchange and skills practice. The teacher also plays an important role in correcting misperceptions that may arise, and in offering information as needed.[xli] The specific techniques that work well in this process are role-plays, Socratic questioning, simulations, brainstorming, cooperative learning, peer-to-peer discussion and service-learning projects.
Best advice 6: universal substance education needs to emphasize student-to-student, rather than student-to-teacher, interactivity; this may involve role-plays, Socratic questioning, simulations, brainstorming, cooperative learning, peer-to-peer discussion and service-learning projects.
Teacher/leader qualities While most evaluated programs have been led by trained teachers, many others, particularly peers, have also led programs. Gottfredson and Wilson (2003), in their meta-analysis of 94 drug education programs, found programs that were led by peers unassisted by teachers to be clearly more effective than teacher-led programs or programs co-led by teachers and peer leaders.[xlii] A common role for peer leaders is to lead the normative component of the program to enhance the believability of normative information on drug use.[xliii] Often peer leaders gain greater benefit than classroom students from peer led programs.[xliv] Cautions have been identified in using peer leaders, particularly the need for careful selection and training of appropriate leaders.[xlv] [xlvi] Peer programs also require more planning. Practical considerations include timetabling, peer training, peer leader absence, length of time between peer leader training and their use in the classroom, and any additional funding required to conduct such programs.[xlvii] The Tobler et al 1998 meta-analysis found mental health practitioners and peer leaders were superior to general classroom teachers, but not significantly.[xlviii] It is often concluded that drug education is best taught by classroom teachers due to: the challenges of sustaining a peer-led program; their having first-hand knowledge of students' needs and developmental level, andbeing best placed to deliver (and if necessary to modify) program components at an appropriate time and level for their students.[xlix] The question of who delivers is quite possibly secondary to the question of what qualities are important for the person who delivers. It is speculated that mental health practitioners are effective because they have skills and training in facilitation and group process, for example creating a non-judgmental atmosphere, being comfortable in a non-directive role (e.g., with ambivalence, and with remaining silent to facilitate dialogue). Regardless of who is delivering, best results can be expected from selecting teacher/leaders with these qualities, acquired through some mix of personal attributes and pre- or in-service training.[l] Guest presenters are often considered for drug education sessions. Given this evidence, it is important that guest presenters be able to address curriculum objectives and work interactively with the students, rather than present an isolated session unconnected with the curriculum.[li] Newer interactive technologies (e.g., CD-ROM, DVD, Internet) to present or reinforce relevant knowledge and skills may be a useful adjunct to classroom prevention programs.[lii]
Best advice 7: classroom lessons are best led by teachers or leaders that are comfortable with and have competence in promoting interactivity among students on substance use issues. Teachers / leaders need to create a non-judgmental atmosphere in order to effectively lead these activities.
Timing of program
Elementary school While relatively few in number, elementary school programs (for children aged 6-12 years) aiming to prevent later substance use do exist and a few have been evaluated. A challenge for these programs is the length of time required for follow-up in order to show results. When asked, teachers suggested that early elementary school drug education is best suited to address the safe handling of medication and alternatives to medication and that drug issues are best placed within much broader questions such as “how do I make healthy decisions about life” and “how do I make decisions about my health”.[liii] Overall, there is little evidence supporting the effectiveness of drug education curriculum at the elementary level.[liv] [lv] [lvi] The limited literature available suggests that elementary school interventions should focus more so on fundamental risk factors and devote attention to family/parent programming, school organisation and behavioural management.[lvii] (See the sections on Targeted and Comprehensive Whole School Approaches).
Middle/Junior High School Most drug education programs and evaluations are directed to middle/junior high school students. Gottredson and Wilson (2003) found that programs directed to this population were more effective than those directed to younger and older students, but that the effects were weak in all cases.[lviii] [lix] The meta-analysis by Roona et al (2000) found that the most effective method at this level was the social influence model.[lx] Senior High School Another approach to determining timing of programming is to base the decision on local student drug use data. McBride (2003) has put forward a three-stage approach that is based on students' behavioural development and use patterns.[lxi] No evidence was found on the value of this approach but it is based on data and theory. The suggested age ranges presented here are based on the general Canadian picture (if there is reason to believe that the situation differs in a particular school or region, the curriculum should be adjusted accordingly).
According to this approach, the first stage of drug education is inoculation, which should occur prior to the average age of first use of a substance but when interest in the substance is occurring (e.g., for alcohol, about age 11-12 years or Grade 5-6). Early relevance, when most students are experiencing initial exposure and some are experimenting with the substance is the second stage (e.g., for alcohol about 13-14 years of age or Grade 7-8). An increasing number of students are beginning to use alcohol at this time, so providing relevant interactive opportunities to engage on issues relevant to them is likely to have meaning and practical value. The third and final stage is later relevance. The later relevance stage should be delivered at a point when students are exposed to higher risk forms of use, different situations, and/or different substances (e.g., alcohol, 15-17 years of age or Grade 9-11). Later relevance messages need to account for the level and pattern of use (for example, an alcohol abstinence message in a class where 60-70% of the students have used in the past year, and a quarter to a third have been drunk, will likely not be taken seriously by many). Recognizing that those students who choose not to use need to be supported in that decision, strategies for promoting safety and minimizing hazardous patterns of use also need to be considered for relevant substances at this point.[lxii] Programs can be best tailored to a population by using local prevalence data.[lxiii] [lxiv] It is likewise important to have some insight into local youth culture, which tends to evolve rapidly.[lxv] This represents an impossible challenge to most adults so it is best accomplished through activities that allow students to create their own ‘real world’ scenarios.[lxvi] Doing this builds in a flexibility that allows the targeting of drug issues as they arise or become pertinent, and the delivery of sessions that engage students with real, rather than abstract, scenarios.
Program length Does the number of program hours have a bearing on effectiveness? In the literature this question is often discussed in terms of duration (e.g. number of weeks it takes to deliver the program) and intensity (e.g. hours per session and sessions per week). It has been commonly accepted that when it comes to program effectiveness, more program hours is better.[lxvii] [lxviii] [lxix] For example, McBride suggests that 10 or more sessions per year through junior high school is preferable but if that is not possible, to follow the initial 10-session module with 4-8 sessions, followed by 3-8 second boosters and, if prevalence indicates, 3-5 third boosters in each subsequent year.[lxx] White and Pitt (1998) in their review of programs focusing on illicit drugs found that 80% of effective programs had 10 or more sessions.[lxxi] However, Cuiper 2002 concluded that there is no definite evidence that intense programs are more effective than less intense programs.[lxxii] Gottfredson and Wilson (2003) found no difference in effectiveness between programs longer than 4.5 months duration and those shorter, but they acknowledged that duration may be a poor proxy for number of contact hours. [lxxiii] [lxxiv]
While it remains clear that ‘one-offs’ or occasional presentations have no measurable effect on behaviours,[lxxv] [lxxvi] the research on this question is not clear, and it may be in part due to confusion around the terms “intensity” and “duration”. Evidence concerning booster sessions (i.e. shorter programs [3-5 sessions] offered in succeeding years to reinforce concepts and skills) is similarly mixed. Skara and Sussman (2003) found that programs using booster sessions were less likely to decay over the longer term (2 or more years), [lxxvii] while Gottfredson and Wilson (2003) found no evidence that booster sessions improved outcomes.[lxxviii] It may seem counterintuitive that a shorter program can be as effective as a longer one, but brief interventions (1-6 sessions) have been found effective with various higher risk populations (See Section IV C, Targeted Curriculum and Services for Higher Risk Students). While awaiting research to provide more clarity on this, decisions around program length are best driven by the particular aims of a program, bearing in mind that recommended interactive programs tend to require more time to process than lecture-based programs.
Delivering program as designed The extent to which Canadian schools or boards use evidence-based drug education curriculum is unknown and it is not known how fully teachers implement the programs they do use. Across the U.S., Rorbach and colleagues (2005) found that less than half the school districts (i.e. boards) reported using evidence-based curriculum in at least one middle school.[lxxix] How a particular program is identified for use in a district is an important question, with this same study finding that district drug coordinators had the most influence, followed by principals and teachers. A number of drug education-related studies have shown that programs are more likely to have a significant impact on key outcomes when they are delivered as intended.[lxxx] This is referred to as delivering the program with “fidelity” and it has been measured in five ways: (1) adherence to the program; (2) the amount delivered; (3) quality of program delivery; (4) participant responsiveness; and (5) program differentiation [extent to which key elements are present].
A survey of a national sample of U.S. middle school drug educators found that most of these teachers reported presenting the content as designed but fewer than 1 in 5 reported that they used interactive teaching methods more often than non-interactive methods, and only 14% implemented both content and process as designed.[lxxxi] Similarly when Sobeck and colleagues (2006) checked teachers' logs in a local survey, they found that interactive lessons were least likely to be used.[lxxxii] The extent to which teacher deviation or adaptation should be discouraged has been debated, with some contending that any “program drift” will diminish outcomes and others arguing that some adaptation to meet local needs is often acceptable and necessary.[lxxxiii] However, if the most common adaptation or deviation is to deliver interactive programs in a didactic manner, outcomes are undoubtedly being affected and this should be viewed as a serious problem. See Section V. G., Factors Affecting Program Implementation in the Real World, for discussion on implementation and capacity issues.
Conclusion A challenge for universal curriculum-based programs is in arriving at a successful “one size fits all” program.[lxxxiv] Universal programs are unable to tailor their content for minority groups or for higher risk youth who may be in those classes. Therefore, the intensity, dosage, content and method of delivery may not match particular needs. It appears that universal programs are more effective with lower-risk students. Nevertheless, the literature points to modest, short-term effects for universal classroom substance education programs. Evidence-based interactive programs directed to middle/junior high school students have shown more promise than other levels. They can be expected to delay or prevent onset of use, hazardous use and harmful consequences among some of the students exposed to the programming. This modest effectiveness can translate into a sizable public health benefit with broadly delivered programs. Caulkins (2002) estimated that for every $US150 per participant in a school program (he based the analysis on Project ALERT) $US840 is saved in health care, economic, and social costs.[lxxxv] This figure takes into account that the studied program, as is the case for even the more effective programs, is not able to sustain its effects beyond a year or two. (For more information on cost effectiveness of this and other models, see Section V. F. Cost Effectiveness in Preventing Substance Use Problems through Schools).
Indeed, to put the effectiveness of school drug education into perspective, Tobler and Stratton (1997) note that the average effect size of interactive programs (averaging 10 hours duration) at 0.2 compares favourably to effectiveness trials in the medical field, where for example it was deemed unethical to withhold the release of aspirin because of its effect size of 0.035.[lxxxvi] So, universal junior high school curriculum-based programs have the potential to provide an important contribution to the prevention of adolescent substance use problems. The evidence is weaker for elementary and senior high school curriculum-based programs. But even with active and widespread dissemination of evidence-based programs and guidelines in the U.S., research in that country has shown that the use of evidence-based school drug education programs is not common in that country. Moreover, the evidence-based programs in use in the U.S. are often not being delivered as intended. The situation in Canada isn’t known but doesn’t likely differ greatly. B. Universal curriculum with aims other than abstinence Over the past 10 years, some researchers have increasingly advocated for the implementation and testing of school drug education programs that include attention to outcomes other than abstinence from substances.[lxxxvii] [lxxxviii] [lxxxix] This is based on the fact that a significant percentage of students in Western societies use alcohol and other substances (particularly cannabis) in the later high school years, often in risky ways. However current school programs often do not reflect this reality. In this context, a program that promotes abstinence as the only viable option may not be taken seriously by students.[xc] [xci] Even though official U.S. drug policy does not support outcomes to interventions other than abstinence, a U.S. review has expressed support for this approach. As a result of their meta-analysis, Roona and colleagues (2000) concluded that “promoting abstinence may not be a viable objective when substance use is normative in the culture, but preventing abuse and its attendant harms may be viable” (p. 20).[xcii] Since a mistake or poor choice can result in drug-related harm or even death, high school students need to be encouraged to avoid hazardous patterns of use common in that population, and when hazardous use has occurred, to avoid harms. By neglecting to give attention to risky patterns or situations and how to avoid them or to minimize harms associated with them, a program misses an important opportunity to provide practical – possibly lifesaving – instruction on this issue.[xciii] This message is best presented alongside a message that identifies abstinence as the most promising option for avoiding risks and harms.
McBride suggests replacing resistance skills training (which has been shown to be based on faulty assumptions) with skills training to help youth reduce hazardous use patterns and harms when they do occur.[xciv] There is limited information on when to introduce these types of aims and messages, but the decision is best made on the basis of the consumption patterns in a region – the most relevant information being the prevalence of hazardous patterns (e.g., binge drinking, drunkenness, use of more than one substance, and use in risky situations such as before driving), however, the prevalence of past year use of a substance is also relevant (this may be the only information available for cannabis and other illegal substances). Each school board and health district needs to make its own determination on when, based on local data, it is necessary to focus on reducing hazardous patterns of use.
For example, if in Nova Scotia (based on 2002 data) a rate of 50% or more of students having used alcohol or 25% having gotten drunk in the past year were seen as benchmarks, then a focus on reducing patterns of hazardous alcohol use would begin in Grade 9. This type of safety-oriented instruction should be provided within an overall message emphasizing abstinence as the safest option. This has been referred to as “harm reduction” education and it has been controversial, with some stakeholders feeling uneasy about the approach. Research in Nova Scotia found that harm reduction messaging was viewed by stakeholders (i.e. parents, health officials, school personnel, and students) in 1998-2002 as acceptable with senior high school populations and not acceptable at the junior high level (with less clarity around Grade 9 appropriateness).[xcv]
A common concern around use of this strategy with younger students was that they didn’t have the capacity to make informed decisions concerning the context of substance use. This study didn’t distinguish between substances in discussions around acceptability. The use of the term harm reduction for this kind of instruction is a red flag for some, and in some cases, may not even be a fully accurate term; much of it would be more accurately termed hazardous use reduction or simply demand reduction. According to definitions proposed by Stockwell (2006), harm reduction best refers to programs or policies that do not necessarily call for reduced consumption or a change in consumption pattern on the part of the user.[1] Accordingly, instruction aiming to delay the onset of use, or reduce the frequency of use, the amount used or other hazardous use by students would all be considered “demand reduction”. The following are examples of hazardous use prevention or harm reduction messages relevant to adolescent populations, noting there is no research evidence to support their use at this point:
Hazardous use prevention:
- Do not use too much or combine two drugs – this use greatly increases the chance of unintentional injury and overdose.
- Do not use in risky situations such as before driving a car, boat, ATV or snowmobile, or being in a vehicle operated by a person who has been using, or before using other machinery; before studying or working; before sports or other physical activity; before sexual activity; when pregnant; when using medication; or when sick.
- Most street drugs have uncertain ingredients, which makes the effects of these drugs unpredictable and possibly dangerous. Also, street drugs are illegal, and a criminal record can present real problems in later life. If intent on using, try only a little bit at first to determine the strength of the effect.
- Do not use too often. If you are drinking or using other drugs regularly, ask yourself why? It may be that substance use is becoming too central an activity in your life, possibly masking other problems that you should be dealing with.
Harm reduction:
- Learn the signs and symptoms of overdose for alcohol (and possibly other substances) to allow you to respond effectively when emergency measures are required.
- Closely monitor someone who has used too much to ensure their own safety by, for example, helping them avoid a high-risk context (e.g., driving a vehicle).
- In the case of individuals who appear agitated or restless from use of a substance, provide calm support.
- In cases of ecstasy use, ensure that breaks are taken from dancing. Cool down and drink water regularly (to replace that lost by sweating) to prevent overheating and dehydration. Drinking too much water all at once can also be dangerous. Instead, sipping no more than a pint of water an hour when dancing is recommended.
- These hazardous use reduction and harm reduction messages would be best developed with the active participation of students because they have an understanding of the hazardous patterns and contexts that occur in their community.
Likewise, McBride and Farrington (2004) reported lower levels of total and risky consumption of alcohol, and lower levels of harms associated with alcohol use in their evaluation of what they termed a harm reduction-oriented program (but which would more precisely be considered a mix of demand reduction/hazardous use prevention and harm reduction) for 13- to 16-year-old students in Australia.[c] Rather than focusing on skills to resist pressure to use, the School Alcohol Harm Reduction Program (SHAHRP) gave attention to skills to reduce risk and to reduce the impact of the harm. The intervention was conducted in two phases over a 2-year period. The initial phase was implemented during the first year of secondary school when the majority of students were 13 years of age. It consisted of 17 skill-based activities conducted over eight to ten lessons (depending on lesson length of either 40 or 60 minutes).
Phase 2 was conducted in the following year when the students were 14 years of age. It consisted of 12 activities delivered over 5–7 weeks. The program activities incorporated various strategies for interactive dissemination including delivery of utility information; skill rehearsal; individual and small group decision making; and discussions based on scenarios suggested by students, with an emphasis on identifying alcohol-related harm and strategies to reduce harm. The program allowed students to discuss and practice behaviours in a low-risk situation, using real-life scenarios, giving them relevant skills they could take with them into actual situations. The authors reported that the results of this approach show behavioural change equal to or greater than programs that have adopted a resistance skills training approach. At 15 months following program completion, differences between intervention and comparison students were beginning to converge; nevertheless at that point students who participated in the program consumed 9% less alcohol, were 4.2% less likely to consume to hazardous levels, experienced 23% less harm from their own use of alcohol and 13% less harm from others’ use of alcohol than did the comparison group.[ci]
These are encouraging results and call for more investigation of the effectiveness of school-based programming aiming to reduce hazardous use and possible harms among students. While the rationale is sound and the few findings are promising, it has been argued that the bar for evidence needs to be set particularly high for school programming that accepts youth activity that falls outside the law. As noted by Poulin (2005), school administrators have a duty of care to under-aged youth through the law and formal policy.[cii] It could be argued that well-based hazardous use prevention and harm reduction programming is in fact an important contribution to a school’s duty of care responsibilities; nevertheless, that contention needs to be supported by more research to fully demonstrate the effectiveness of school prevention programs that include hazardous use prevention or harm reduction elements. In the meantime, schools and communities need to continue to seek acceptable responses to widespread hazardous use of alcohol and to a lesser extent other substances by young people in this country.
End Notes
[1] In an attempt to reduce the confusion still surrounding these terms, Stockwell (2006) has proposed a breakdown drawn from a public health perspective which recognizes the need to address the agent (through supply reduction), the individual (through demand reduction) and the environmental context (harm reduction). · Supply reduction: strategies that are intended to achieve social, health, and safety benefits by reducing the physical availability of a particular substance. · Demand reduction: strategies which succeed by motivating users to consume less overall and/or less per occasion, but don’t necessarily call for abstinence. · Harm reduction: strategies that reduce the likelihood of harm to health and safety without necessarily requiring a change in the pattern or level of substance use.
[i] McBride, N. (2004). School drug education: A developing field and one element in a community approach to drugs and young people: A response to the commentaries. Addiction, 99(3), 296.
[ii] Flay, B.R. (2000). Approaches to substance use prevention utilizing school curriculum plus social environment change. Addictive Behaviors, 25(6), 861-885.
[iii] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023.
[iv] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[v] Flay, B.R., & Petraitis, J. (1994). The theory of triadic influence. A new theory of health behavior with implications for preventative interventions. Advances in Medical Sociology, 4, 19-44.
[vi] Botvin, G. J. (2000). Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors, 25(6), 887-897.
[vii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[viii] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50.
[ix] Allott, R., Paxton, R., & Leonard, R. (1999). Drug education: A review of British government policy and evidence on effectiveness. Health Education Research: Theory & Practice, 14(4), 491-505.
[x] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50.
[xi] Allen & Clarke Policy and Regulatory Specialists Ltd. (2003). Effective drug education for young people: Literature review and analysis. Retrieved August 31, 2007, from http://www.myd.govt.nz/uploads/docs/0.7.1.1%20effective%20drug%20ed.pdf
[xii] Sheppard, M.A., Wright, D., & Goodstadt, M.S. (1985). Drug use and peer pressure: Exploding the myth. Adolescence, 20(80), 949-958.
[xiii] Botvin, G. J. (2000). Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors, 25(6), 887-897.
[xiv] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023.
[xv] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[xvi] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023. [xvii] Hansen, W., & Graham, J. (1991). Preventing alcohol, marijuana, and cigarette use among adolescents: Peer pressure resistance training versus establishing conservative norms. Preventive Medicine, 20(3), 414-430.
[xviii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[xix] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[xx] Agostinelli, G. & Grube, J. (2002). Alcohol counter-advertising and the media: A review of recent research. Alcohol Research and Health, 26(1), 15-21.
[xxi] Perkins, H., Haines, M., and Rice, R. (2005). Misperceiving the college drinking norm and related problems: A nationwide study of exposure to prevention information, perceived norms and student alcohol misuse. Journal of Studies on Alcohol, 66, 470-478.
[xxii] Schultz, W., Nolan, J., Cialdini, R., Goldstein, N., Griskevicius, V. (2007). The Constructive, Destructive, and Reconstructive Power of Social Norms. Psychological science, 18(5).
[xxiii] Granfield, R. (2004). Alcohol use in college: Limitations on the transformation of social norms. Addiction Research and Theory, 13(3), 281–292.
[xxiv] Botvin, G. J. (2000). Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors, 25(6), 887-897.
[xxv] ibid
[xxvi] Tobler, N.S., & Stratton, H.H. (1997). Effectiveness of school-based drug prevention programs: A meta-analysis of the research. The Journal of Primary Prevention, 18(1), 71-128.
[xxvii] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf
[xxviii] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50.
[xxix] Coggans, N., Cheyne, B., & McKellat, S. (2002). The life skills training drug education programme: A review of research. Retrieved August 31, 2007, from http://www.drugmisuse.isdscotland.org/eiu/pdfs/eiu_lifeskl.pdf
[xxx] Foxcroft, D., Ireland, D.J., Lister-Sharp, D., Lowe, G., & Breen, R. (2003). Longer-term primary prevention for alcohol misuse in young people: A systematic review. Addiction, 98, 397-411.
[xxxi] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf
[xxxii] Vicary, J.R., Smith, E.A., Swisher, J.D., Bechtel, L.J., Elek, E., Henry, K.L., et al. (2006). Results of a 3-year study of two methods of delivery of life skills training. Health education behavior, 33(3), 325-339.
[xxxiii] Foxcroft, D., Ireland, D.J., Lister-Sharp, D., Lowe, G., & Breen, R. (2003). Longer-term primary prevention for alcohol misuse in young people: A systematic review. Addiction, 98, 397-411.
[xxxiv] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf
[xxxv] Tobler, N.S. (2000). Lessons learned. The Journal of Primary Prevention, 20(4), 261-274.
[xxxvi] Tobler, N.S., & Stratton, H.H. (1997). Effectiveness of school-based drug prevention programs: A meta-analysis of the research. The Journal of Primary Prevention, 18(1), 71-128.
[xxxvii] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023.
[xxxviii] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf
[xxxix] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[xl] Tobler, N.S., & Stratton, H.H. (1997). Effectiveness of school-based drug prevention programs: A meta-analysis of the research. The Journal of Primary Prevention, 18(1), 71-128.
[xli] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[xlii] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38.
[xliii] Skara, S., & Sussman, S. (2003). A review of 25 long-term adolescent tobacco and other drug use prevention program evaluations. Preventive Medicine, 37, 451-474.
[xliv] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[xlv] Loxley, W., Toumbourou, J.W., & Stockwell, T. (2004). The prevention of substance use, risk and harm in Australia: A review of the evidence. Retrieved September 30, 2007, from http://www.aodgp.gov.au/internet/wcms/publishing.nsf/content/health-pubhlth-publicat-document-mono_prevention-cnt.htm
[xlvi] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf
[xlvii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742. [xlviii] Tobler, N.S. (2000). Lessons learned. The Journal of Primary Prevention, 20(4), 261-274.
[xlix] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[l] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf
[li] Buckley, E.J., & White, D.G. (2007). Systematic review of the role of external contributors in school substance use education. Health Education, 107(1), 42-62.
[lii] Williams, C., Griffin, K.W., Macaulay, A.P., West, T.L., & Gronewold, E. (2005). Efficacy of a drug prevention CD-ROM intervention for adolescents. Substance Use and Misuse, 40(6), 869-878.
[liii] Godfrey, C., Toumbourou, J.W., Rowland, B., Hemphill, S., Munro, G., & Farrell, C. (2002). Drug education approaches in primary schools [Prevention research evaluation report No. 4]. Retrieved September 30, 2007, from http://www.druginfo.adf.org.au/download.asp?RelatedLinkID=578
[liv] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38.
[lv] Godfrey, C., Toumbourou, J.W., Rowland, B., Hemphill, S., Munro, G., & Farrell, C. (2002). Drug education approaches in primary schools [Prevention research evaluation report No. 4]. Retrieved September 30, 2007, from http://www.druginfo.adf.org.au/download.asp?RelatedLinkID=578
[lvi] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf
[lvii] Godfrey, C., Toumbourou, J.W., Rowland, B., Hemphill, S., Munro, G., & Farrell, C. (2002). Drug education approaches in primary schools [Prevention research evaluation report No. 4]. Retrieved September 30, 2007, from http://www.druginfo.adf.org.au/download.asp?RelatedLinkID=578
[lviii] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38.
[lix] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf
[lx] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf [lxi] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742. [lxii] ibid [lxiii] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf [lxiv] White, D., & Pitts, M. (1998). Educating young people about drugs: A systematic review. Addiction, 93(10), 1475-1487. [lxv] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50. [lxvi] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf [lxvii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742. [lxviii] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38. [lxix] White, D., & Pitts, M. (1998). Educating young people about drugs: A systematic review. Addiction, 93(10), 1475-1487. [lxx] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742. [lxxi] White, D., & Pitts, M. (1998). Educating young people about drugs: A systematic review. Addiction, 93(10), 1475-1487 [lxxii] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023. [lxxiii] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38. [lxxiv] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf [lxxv] Dusenbury, L., Falco, M., & Lake, A. (1997). A review of the evaluation of 47 drug abuse prevention curricula available nationally. Journal of School Health, 67(4), 127-132. [lxxvi] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Geneva, Switzerland: World Health Organization. [lxxvii] Skara, S., & Sussman, S. (2003). A review of 25 long-term adolescent tobacco and other drug use prevention program evaluations. Preventive Medicine, 37, 451-474. [lxxviii] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38. [lxxix] Rohrbach, L.A., Ringwalt, C.L., Ennett, S.T., & Vincus, A.A. (2005). Factors associated with adoption of evidence-based substance use prevention curricula in US school districts. Health Education Research, 20(5), 514-526. [lxxx] Dusenbury, L., Brannigan, R., Falco, M., & Hansen, W.B. (2003). A review of research on fidelity of implementation: Implications for drug abuse prevention in school settings. Health Education Research: Theory and Practice, 18(2), 237-256. [lxxxi] Ennett, S.T., Ringwalt, C. L., Thorne, J., Rohrbach, L.A., Vincus, A., Simons-Rudolph, A., & Jones, S. (2003). A comparison of current practice in school-based substance use prevention programs with meta-analysis findings. Prevention Science, 4(1), 1-14. [lxxxii] Sobeck, J.L., Abbey, A., & Agius, E. (2006). Lessons learned from implementing school-based substance abuse prevention curriculum. Children & Schools, 28(2). [lxxxiii] Ringwalt, C.L., Ennett, S., Johnson, R., Rohrbach, L.A., Simons-Rudolph, A., Vincus, A., & Thorne, J. (2003). Factors associated with fidelity to substance use prevention. Curriculum guides in the nation’s middle schools. Health Education & Behavior, 30(3), 375-391. [lxxxiv] Allen & Clarke Policy and Regulatory Specialists Ltd. (2003). Effective drug education for young people: Literature review and analysis. Retrieved August 31, 2007, from http://www.myd.govt.nz/uploads/docs/0.7.1.1%20effective%20drug%20ed.pdf [lxxxv] Caulkins, J.P. (2002). School-based drug prevention: What kind of drug use does it prevent? Retrieved August 31, 2007, from http://www.rand.org/pubs/monograph_reports/2007/MR1459.pdf [lxxxvi] Tobler, N.S., & Stratton, H.H. (1997). Effectiveness of school-based drug prevention programs: A meta-analysis of the research. The Journal of Primary Prevention, 18(1), 71-128. [lxxxvii] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf [lxxxviii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742. [lxxxix] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf [xc] Rosembaum, M. (2002). Safety first: A reality-based approach to teens, drugs, and drug education. Retrieved August 31, 2007, from http://www.safety1st.org/images/stories/pdf/safetyfirst.pdf [xci] Kay, J. (1994). Don’t wait until it’s too late. International Journal of Drug Policy, 5(3), 166-175. [xcii] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf [xciii] Rosembaum, M. (2002). Safety first: A reality-based approach to teens, drugs, and drug education. Retrieved August 31, 2007, from http://www.safety1st.org/images/stories/pdf/safetyfirst.pdf [xciv] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742. [xcv] Poulin, C., & Nicholson, J. (2005). Should harm minimization as an approach to adolescent substance use be embraced by junior and senior high schools? Empirical evidence from an integrated school and community-based demonstration intervention addressing drug use among adolescents. International Journal of Drug Policy, 16, 403–414. [xcvi] Paglia, A., & Room, R. (1999). Preventing substance use problems among youth: A literature review and recommendations. Journal of Primary Prevention, 20(1), 3-50. [xcvii] Brounstein, P., Gardner, S.E., & Backe, T.E. (2006). Research to Practice: Efforts to Bring Effective Prevention to Every Community. The Journal of Primary Prevention, 27(1). [xcviii] Roona, M., Streke, A., Ochshorn, P., Marshall, D., & Palmer, A. (2000). Identifying effective school-based substance abuse prevention interventions. Retrieved August 31, 2007, from http://silvergategroup.com/public/PREV2000/Roona.pdf [xcix] Poulin, C., & Nicholson, J. (2005). Should harm minimization as an approach to adolescent substance use be embraced by junior and senior high schools? Empirical evidence from an integrated school and community-based demonstration intervention addressing drug use among adolescents. International Journal of Drug Policy, 16, 403–414. [c] McBride, N., Farringdon, F., Midford, R., Meuleners, L., & Phillips, M. (2004). Harm minimization in school drug education: Final results of the school health and alcohol harm reduction project (SHAHRP). Addiction, 99(3), 278-291. [ci] ibid [cii] Poulin, C. (2006). Harm reduction policies and programs for youth. Harm reduction for special populations in Canada #2. Retrieved September 12, 2007, from http://www.ccsa.ca/NR/rdonlyres/D0254373-5F2B-459D-BB79-6EE7C22CC303/0/ccsa113402006.pdf
Curriculum Design -Targeted, Secondary Prevention
This page presents advice about curriculum and program design for targteted programs aimed to serve students at higher risk of substance abuse.
Targeted curriculum and services for higher risk students An excerpt from "School-based and school-linked prevention of substance use problems: A knowledge summary", Canadian Association for School Health, 2008. Universal drug education curricula have been criticized for having insufficient focus and intensity to effectively address the needs of higher risk youth. Studies of the effect of universal programs on substance-using youth have shown either no effect or an increase in use.[i] [ii] Youth may be considered higher risk on the basis of the accumulation of risk factors they are living with or on the basis of already engaging in early, hazardous substance use. Some researchers and programmers group these populations together as “targeted” populations; others distinguish between them, referring to “Selective” prevention for those living with various risk factors (e.g. family and school factors), and “Indicated” prevention for those using substances in a hazardous way, but not at the level of dependency. Because there is significant overlap between these two populations during adolescence (i.e. adolescents with a number of risk factors tend to use substances more hazardously) and the evaluation research does not define these areas of risk in a consistent way, this review will group all programming directed to at-risk students together but specify the characteristics of the target group as closely as possible.
It has been suggested that the young people who benefit from targeted programming are those who present a “life course deviance” profile (as opposed to adolescence-limited).[iii] [iv] They have often experienced a range of challenges in earlier childhood as summarized in Section IV. Early substance use is considered an important risk factor for ongoing problems (e.g., school truancy and drop-out, theft, violence, heightened sexual activity, substance dependence and suicide), but the early use is itself usually an outgrowth of earlier factors. Consequently, while programming in early adolescence when unhealthy behaviours may be forming is called for, so too is programming earlier in the life course when risk factors may be more amenable to change.[v]
Early childhood/elementary level multi-component programs
Because of the length of the follow-up period, only a few studies have assessed effects of elementary level programming on later substance use, but those few have generally produced positive results on substance use outcomes.[vi] [vii] These early school interventions do not pay direct attention to substance use but rather aim to improve educational environments, reduce social exclusion and aggressive and disruptive behaviour.[viii] [ix] Notably, they almost always have more than one component. Apparently central to the success of these programs is the school-parent partnership that leads parents and teachers to feeling more supported in their efforts and results in more success than those that target either teachers or parents or children alone.[x] As is often the case with multi-component interventions, the extent to which each component is responsible for the behaviour change is not clear for these interventions.
Well designed targeted pre and early school programming can have long-term impact on a range of problem behaviours.[xi] In what would be regarded in the context of this report as a “school-linked” program, the well-known High/Scope Perry Preschool Program (Michigan) showed enduring impact. This randomized study followed at-risk children to age 40 and found that those receiving a daily high quality (including low child-teacher ratio) 2.5 hour class in addition to weekly family visits for two pre-school years obtained positive life-long benefits in a range of life areas, including academic achievement, income, criminal activity and substance use, when compared to controls.[xii] While intensive, the program demonstrated cost effectiveness (see Section V. F.).
The Montreal Longitudinal Experimental Study for high-risk boys included classroom social-cognitive skills training and a home-based parent training program over two years (ages 7-9). Tremblay and colleagues identified 366 disruptive boys at age 6, and randomly assigned them to experimental and control conditions. The boys in the experimental condition received school-based training to foster social skills and self-control. Coaching, peer modeling, role playing, and reinforcement were used in small group sessions on topics such as, “What to do when you are angry” and “How to react to teasing.” Also, their parents were trained at home approximately once every 3 weeks over a 2-year span. (The average number of sessions was 17.4.) The combination of parent and child training for these high-risk children in kindergarten and first grade reduced rates of delinquency and school adjustment problems at age 12. By age 12, the boys in the experimental condition were less likely to get drunk, committed less theft, were less likely to be involved in fights and had higher achievement than controls. The program also demonstrated a snowball effect in that the differences between the experimental and control boys increased as time went on.[xiii]
In the U.S., researchers with the Fast Track project are studying the effects of a multi-component school and family intervention to shift the trajectory of children considered to be at high risk for later anti-social and problematic behaviours. Fast Track is a randomized, controlled trial that distributed 891 children from 55 schools between intervention and control conditions. The theoretic underpinning of this trial is that aggressiveness is an important risk factor for a number of later academic and social problems and that it arises from a mix of individual, family and school factors that cluster, interact and amplify each other in some children (for example, disruptive temperament in early childhood and weak parenting practices have the effect of aggravating and worsening each other). This large trial identified children in kindergarten who were beginning to show signs of disruptive behaviour at home and school, and provided a mix of family and school interventions from Grade 1 through to Grade 10 with heavier programming in the first two years of elementary school and at the transition to middle school. Interventions included parent training, home visits, children’s social skills groups, peer-pairing sessions and a universal social skills development curriculum; the aim was to improve relationships with parents during the early primary school years, and (starting in grade 1) improve home-school relations, and the child’s social problem solving, peer relations, school bonding and academic performance. The ultimate goals are to reduce various problematic behaviours (e.g. violent and aggressive behaviour, substance use, delinquency, risky sexual behaviour, and mental health problems) during adolescence and into adulthood.
The latest reported follow ups (end of grade 5) showed improvements in social functioning, deviant peer involvement, and serious antisocial behaviour in their home and community, but notably did not have an effect on academic performance or school behaviour. It remains to be seen whether the relatively small effects seen in these areas of functioning will have an impact on later substance use.[xiv] The program had much more effect on higher risk children with fewer than half as many cases of conduct disorder diagnosed in the intervention group as in the control group at grade 5. A discussion of program costs vs. costs of crime and delinquency concluded that the program was cost-effective in reducing conduct disorder and delinquency, but only for those who were very high-risk as young children.[xv]
Best advice 8: organize targeted elementary school programming to help parents and teachers impart basic personal and social skills to higher risk children; this programming can help students learn and prevent later problem behaviours, including hazardous substance use.
School-linked targeted family programs
It appears that “family-based” interventions are more effective than “parent-only” or “child only” programming in building protective factors and reducing substance use.[xvi] For example, the Focus on Family Program, consisting of parent skill building without an intervention for children showed no effect on children’s substance use.[xvii] Typically, effective family programming aims to build relationship and communication skills separately among the parents and the children, along with opportunities to learn and practice skills as a family unit. These programs have shown positive effects on a number of risk and protective factors and have brought about reductions in youth substance use. The provision of transportation, food and childcare during sessions, as well as advocacy and crisis support programs increase the likelihood of attracting and retaining families and are considered important elements of these programs.[xviii]
The Strengthening Families Program (SFP) is a well-replicated example of a family program that has been shown to be effective with targeted as well as universal populations (See Section D, Comprehensive Whole School Approaches). The program involves whole families coming together in a school, community centre, or other public place. The format for each week of the 14 session SFP involves parents and children first participate in skill-building activities after which families come together to practice the skills (e.g. communication and conflict-resolution skills). Free meals, transportation, and childcare are provided.
The SFP has been evaluated in several randomized control trials over a five-year follow-up period. The results showed that, compared with the control group, children in the experimental groups were significantly less likely to use substances and engage in other adolescent problem behaviours. The program has been adapted with positive results for lower risk families, families with older children and families of various cultural backgrounds.[xix]
A recent adaptation involved a three-year multi-site randomized controlled trial with Ontario families (along with families in New York State) recently affected by alcohol problems. To be eligible for the study, parents must have had an alcohol problem in the past five years and primary parenting responsibility for a child age 9-12 years. Over the 14-week period, the Ontario SFP families met once a week in the evening for three hours. The program contained four components: dinner hour, Child Skills Training Program, Parent Skills Training Program, and Family Skills Training Program. Four trained facilitators delivered the program sessions (two in the parent session and two in the child session). SFP participants also attended a two-hour booster session delivered immediately after the first study follow-up assessment designed to reinforce the skills taught in the 14-week program. In addition to the assessment immediately following the program, families were assessed at 4 months and 12 months after program completion. The control group received the Parent Intervention Program which comprised written material on parenting and local contact information. Although the trial has not published its results, the author has reported immediate and sustained positive effects for several family and child psychosocial outcomes, including: improved family functioning, more effective parenting techniques, reduced parent hostility and aggression, reduced symptoms of parent depression, reductions in children’s externalizing behaviour problems, better child social skills and better child coping skills. SFP children also displayed a 37% reduction in alcohol sipping relative to controls.[xx]
A review of targeted family programs has concluded that effective programs:[xxi]
Best advice 9: consider family skills programs to help higher risk families with elementary age children improve relationship skills; these programs can contribute significantly to family and child health and prevent later youth substance use.
Middle/high school programs
The most commonly evaluated approach to working with at-risk pre- and early adolescent youth is school-based life-skills programming.[xxiii] Programs targeting young at-risk adolescents in transition school years have been evaluated in Canada and the U.S. Ontario’s Opening Doors program by DeWitt and colleagues (2000) assessed an in-school program aimed at preventing or reducing drug use and other deviant behaviour in high-risk young people during their transition from Grade 8 to 9.[xxiv]
Opening Doors selected high-risk students using a screening test assessing demographic and behavioural characteristics. The program consisted of two separate program components running concurrently – a student program and a parent program. The student program consisted of instruction using a social skills training approach and a peer support component. Seventeen sessions of approximately one hour in length were offered once or twice weekly over a 10-week period. Through group activities and discussion the program aimed to help students develop personal and social skills to enhance their school experience and relationship with peers, teachers, and parents. The program was intended to accommodate 10 to 12 students at a time.
The parent program consisted of five evening sessions of approximately two hours in length held on alternate weeks over the duration of the student program. It was intended to foster a positive home environment in which parents actively support and reinforce their children's school experience. It was hoped that improved parent-child interactions, better management of their children's behavioural problems, and reinforcement and support of the student program would contribute to a reduction of the prevalence and frequency of substance abuse, school drop-out, violent and other antisocial behaviour, and an improvement in academic achievement. Participants in the experimental group showed several behavioural improvements immediately following the program; the effects had eroded by the 6-month follow-up, but were still somewhat in evidence relative to the comparison group. The Opening Doors program is similar to the Reconnecting Youth program tested and widely disseminated in the U.S. In the Reconnecting Youth program, students at risk of dropping out of Grades 9 to 12 were offered “personal growth classes”, small classes offering group support, friendship development, and school bonding. A specific skills training course was also offered based on four units: self-esteem enhancement, decision making, personal control, and interpersonal communication. Those receiving the program reported improvements in school bonding, self-esteem and reductions in deviant peer associations and were less likely to initiate substance use. However, the design of the study was relatively weak and reviewers have called for more rigorous evaluation of this program.[xxv]
Cho et al (2005) replicated the Reconnecting Youth program using a stronger study design and failed to demonstrate positive findings. In fact, at follow-up there were indications of the experimental group doing more poorly than the controls, and the authors raised the possibility that “deviancy training” had occurred among the high-risk youth in the experimental group. As the authors noted, “Clustering high-risk students in the Reconnecting Youth classroom setting provides a consistent opportunity to affiliate and bond with deviant peers and removes the opportunity to spend that time in a regular class with more conventional peers” (p. 371).[xxvi] Until further light is shed on this question, schools should carefully consider the potential for harm when selecting groups of at-risk middle or high school students for special programming.
Programs for Aboriginal students
Because relevance is important in all programming, culturally appropriate substance education programming is likely to increase the potential of programs for First Nations students. However, using Aboriginal culture as simply an “add on” to program content creates only vague awareness of cultural issues. The integration of both Aboriginal content and perception entails a deeper understanding of cultural values, practices and symbols.[xxvii] [xxviii] It also means recognizing that Aboriginal students are not a homogeneous population and can vary greatly in their perspective according to geography and location (e.g. reserve or urban).
In their review of programming for Native American adolescents, Hawkins and colleagues found bi-cultural competence approaches to skills training to be most promising for reducing prevalence of drug use in Native American youth.[xxix] This approach aims to equip young people with coping skills to negotiate between mainstream and Aboriginal cultures.[xxx] In addition to coping skills training, the process of respectful relationship building (i.e., caring and sharing) with teachers, role models and Elders can profoundly influence a young person’s sense of belonging to their community and to society.
Schinke and colleagues (2000) reported a long-term follow-up of a culturally-focused school and community intervention with about 1,400 Native American students in 27 schools in the U.S. Two interventions were tested against a control condition: a school-based skills development program, and the skills plus a community involvement program. Youths in schools assigned to the control arm did not receive any intervention. Students in Grades 3-5 received 15 50-minute weekly sessions that combined conventional cognitive-behavioural skills development with culturally tailored content and activities. Cultural content addressed substance use issues and holistic concepts of health and health promotion among Native people. In the context of culturally specific situations, youths acquired new skills by applying them initially to role-play situations, then subsequently to situations volunteered by youths from their daily lives. The program included exercises that increased students’ awareness of Native cultural traditions that run counter to substance abuse. Every session included homework assignments for youths to gather information and testimonies on relevant topics. The school plus community involvement component aimed at reinforcing the skills developed in school. Substance prevention awareness messages were presented through a number of channels, including the students’ families, teachers and school guidance counsellors, neighbourhood residents, law enforcement officials, and commercial establishments frequented by youths. Flyers and posters were distributed to businesses, health and social service agencies, schools, and churches. Informational meetings were also held for parents, neighbours, and teachers, informing them about intervention components youths were receiving. Informational sessions took place at local schools and included poster-making exercises, mural painting, skits, and problem-solving contests. Semi-annually, students in the two intervention arms received two 50-minute sessions booster sessions.
At the 3.5 year follow-up, both the students in the curriculum and curriculum + community arm were using alcohol and cannabis at a lower rate than the control students; neither intervention had any effect on cigarette use. Notably, the students in the curriculum arm were using these substances at a lower rate than those participating in the curriculum + community arm, which runs counter to accepted wisdom. This interesting finding could reflect networks of communication in a collective society, i.e., extended family culture and its influence on peer support could have impacted the behavioural choices of students participating only in the curriculum. The study reported gender differences and found that boys were more likely to have high rates of alcohol use, while girls were more likely to use cigarettes regularly, and there was little difference with cannabis use. In his Cochrane review, Foxcroft (2003) concluded that this approach is one of the more promising approaches in the adolescent alcohol prevention literature.[xxxi]
Best advice 10: for Aboriginal students, deliver substance education that employs a bi-cultural competence approach to equip students with skills to cope effectively in mainstream and Aboriginal cultures; this approach calls for ongoing trust building and collaboration between schools, public health and Elders and other respected Aboriginal leaders.
Brief interventions
For populations using substances hazardously but who aren’t necessarily dependent, brief interventions employing cognitive-behavioural and/or motivational principles are increasingly used. These approaches, having shown substantial promise for addressing hazardous use of alcohol, tobacco, and other drugs with a range of populations and settings,[xxxii] [xxxiii] [xxxiv] are increasingly being evaluated for the secondary school setting. Cognitive-behavioural approaches focus on methodically building skills to deal with current issues of the client/student. These approaches often include an assessment of the current situation followed by identification of personalised, usually time-limited goals and strategies which are monitored and evaluated. The approach is inherently empowering in nature, the outcome being to focus on acquiring and utilising new skills, with an emphasis on putting what has been learned into practice between sessions through homework. Motivational interviewing, developed by Miller and Rollnick is a person-centered interviewing style with the goal of resolving conflicts regarding the pros and cons of change, enhancing motivation, and encouraging positive changes in behaviour. The interviewer’s style is characterised by empathy and acceptance, with an avoidance of direct confrontation. Any statements about positive behaviour change brought up by the person in the discussion are encouraged to support self-efficacy and a commitment to take action.[xxxv]
There is no consensus on what constitutes a “brief” intervention. Interventions may range from four sessions to 5 min to receipt of one or more feedback sheets in the mail. They are often conducted by a health professional in which case a screening instrument is used to identify those using substances at hazardous levels (for example, the Rutgers Alcohol Problem Index (RAPI), which includes questions designed to assess consequences of problems, such as hangovers, cognitive impairment, and interpersonal conflict).[xxxvi] However because hazardous drinkers are often reluctant to discuss their drinking with a doctor or other practitioner, online self-assessment followed by brief intervention in the form of personalized feedback about one’s drinking has been found to be a popular intervention strategy among younger people.
There is some indication that targeted programming using these formats may be more effective for higher-risk adolescents than universal programs, but the evidence base is small because few programs have been rigorously evaluated. The meta-analysis by Gottfredson and Wilson (2003) found that cognitive-behaviourally oriented programs were more effective for higher-risk youth than others, but they called for more study in this area before drawing firm conclusions. In their review of brief interventions for adolescents, Tait and Hulse (2003) found that brief interventions directed to adolescents were effective across a diverse range of settings (dental clinics, schools, universities, substance treatment centres) and, therefore, probably diverse clients. Most of the interventions reviewed drew on motivational principles; those focusing on alcohol had a small effect, and those addressing tobacco had no effect, while the effect for the few concerned with multiple substances appeared substantial, but the sample was too small to generalize broadly.
Although the size of the effect for these interventions tends to be modest, it needs to be weighed against the amount of contact time involved.[xxxvii] In a review and discussion of school-based brief interventions, Winters and colleagues (2007) did not identify any actually set in schools; they found 3 studies of brief interventions for adolescents based in other settings, all of which showed modest results.[xxxviii]
At the post-secondary level, brief interventions (including online versions) have been found effective in reducing alcohol-related harms, and may have application in senior high school settings. One example is the Brief Alcohol Screening in College Students (BASICS) program which has been found effective in reducing binge and excessive drinking in college students in several long-term follow-up studies. BASICS consists of two one-on-one interviews designed to promote reduced alcohol consumption or abstinence among high-risk drinkers. The format consists of personalised feedback, including descriptive graphs presenting the person’s own drinking patterns in relation to normative trends, negative consequences of drinking, and related attitudes and beliefs. An attempt is made to resolve ambivalence about changing one’s drinking behaviour and to move toward a safer drinking plan.[xxxix]
A promising example of a brief intervention for alcohol problems in the secondary school setting has been rigorously tested in this country. Conrod, Stewart, Comeau and MacLean conducted a randomized controlled trial of the effect of a brief intervention targeting one of three personality profiles: anxiety sensitivity (AS), hopelessness (H), and sensation seeking (SS) in high schools in urban British Columbia and rural Nova Scotia.[xl] [xli] Students were randomly assigned to the appropriate personality intervention or to a no-treatment control group at each site and then reassessed 4 months later. All participating students had consumed alcohol in the previous 4 months; they were viewed as not yet having demonstrated significant drinking problems but at risk for doing so based on their personalities. Interventions were delivered by therapists and research assistants and consisted of two 90-minute sessions spread across 2 weeks; the number of students per group ranged from 2 to 7.
Each intervention incorporated principles from the motivational and cognitive–behavioural literatures. The three main components of the interventions were (a) psycho-education, (b) behavioural coping skills training, and (c) cognitive coping skills training. The interventions began with the psycho-educational component – girls and boys were educated about the personality variable in question and the problematic coping behaviours associated with that personality style. Students were encouraged to discuss the short-term reinforcing properties of a variety of problematic coping strategies (including alcohol use) to help them understand their specific motivations for engaging in problematic and risky behaviours. This was followed by a motivational intervention (weighing the short- and long-term positive and negative consequences of a particular behaviour) around the use of problematic behavioural strategies for coping with that particular personality dimension. Next, cognitive coping skills training helped students learn how to identify and challenge cognitive distortions specific to each personality, using stories and exercises from students’ lives.
These brief interventions led to significantly better outcomes compared to the control group students as measured by rates of abstinence, reduced drinking quantity, binge drinking rates, and alcohol problems. Interestingly, the intervention appeared to have effects on aspect of drinking behaviour particularly linked to each of the personality types. For example, the sensation-seeking group was more likely to engage in binge drinking than the other two personality groups, and the intervention appeared to have more impact on this drinking variable for the sensation-seeking group than the other two groups. The outcomes for this three-hour intervention were quite promising at four months and demonstrate the potential of a well targeted intervention, but it will be important to determine whether the effects are maintained over a longer period, and to replicate findings.
It will also be interesting to learn whether a sustainable delivery format can be found, given that this trial was conducted by specifically trained therapists. A bi-cultural competence approach has also been shown to be effective within a brief intervention program for Aboriginal youth which similarly targets personality and motivational factors.[xlii] Recent community collaboration led to the development and testing of a culturally relevant brief intervention program for First Nation youth in Nova Scotia designed to address the issue of alcohol abuse and prevention of alcohol problems among Mi’maq adolescents. The pilot results were positive in that compared to pre-intervention, students who participated in the intervention drank less, engaged in less binge-drinking episodes, had fewer alcohol-related problems, were more likely to abstain from alcohol use, and reduced their marijuana use at four-months post-intervention. No such significant changes were observed in a non-random group of eligible students who did not participate in the intervention. Future research should determine if the methodology for development of a similar intervention is effective for at-risk youth in other Aboriginal communities across Canada, and whether the promising, but preliminary results with marijuana mean that the benefits of the intervention might extend to adolescents’ use of substances other than alcohol. This 2 x 90 minute program was delivered in a sustainable format through the training of local First Nation school guidance counsellors and police officers as co-facilitators.[xliii]
Best advice 11: with at-risk students (including Aboriginal students), consider school-based brief interventions (fewer than 4 sessions); these interventions, when guided by principles of recognition, respect, sharing, and responsibility, have been found to promote abstinence and reduced hazardous drinking and alcohol problems.
End Notes
[i] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf [ii] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38. [iii] Spooner, C., & Heatherington, K. (2004). Social determinants of drug use [Tech. Rep. No. 228]. Retrieved September 30, 2007, from http://ndarc.med.unsw.edu.au/ndarcweb.nsf/website/Publications.reports.TR228 [iv] Toumbourou, J.W., Rowland, B., Jefferies, A., Butler, H., & Bond, L. (2004). Preventing drug-related harm through school re-organisation and behavior management [Prevention research evaluation report No. 12]. Melbourne, Australia: Australia Drug Foundation. Retrieved September 30, 2007, from http://www.druginfo.adf.org.au/downloads/Prevention_Research_Quarterly/PRQ_04Nov_Early_intervention_in_schools.pdf [v] ibid [vi] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38. [vii] Toumbourou, J.W., Stockwell, T., Neighbors, C., Marlatt, G.A., Sturge, J., & Rehm, J. (2007). Interventions to reduce harm associated with adolescent substance use: An international review. Lancet, 369, 1391-1401. [viii] Webster-Stratton, C., & Taylor, T. (2001). Nipping early risk factors in the bud: Preventing substance abuse, delinquency, and violence in adolescence through interventions targeted at young children (0–8 Years). Prevention Science, 2(3). [ix] Toumbourou, J.W., Stockwell, T., Neighbors, C., Marlatt, G.A., Sturge, J., & Rehm, J. (2007). Interventions to reduce harm associated with adolescent substance use: An international review. Lancet, 369, 1391-1401. [x] Webster-Stratton, C., & Taylor, T. (2001). Nipping early risk factors in the bud: Preventing substance abuse, delinquency, and violence in adolescence through interventions targeted at young children (0–8 Years). Prevention Science, 2(3). [xi] Foley, D., Goldfeld, S., McLoughlin, J., Nagorcka, J., Oberklaid, F., & Wake, M. (2000). A review of the early childhood literature. Retrieved September 30, 2007, from http://www.facs.gov.au/internet/facsinternet.nsf/vIA/families/$file/early_childhood.pdf [xii] Schweinhart, L.J. (2004). The High/Scope Perry Preschool study through age 40. Summary, conclusions, and frequently asked questions. Retrieved September 30, 2007, from http://www.highscope.org/file/Research/PerryProject/3_specialsummary%20col%2006%2007.pdf [xiii] Webster-Stratton, C., & Taylor, T. (2001). Nipping early risk factors in the bud: Preventing substance abuse, delinquency, and violence in adolescence through interventions targeted at young children (0–8 Years). Prevention Science, 2(3). [xiv] Conduct Problems Prevention Research Group. (2004). The Effects of the Fast Track Program on Serious Problem Outcomes at the End of Elementary School. Journal of Clinical Child and Adolescent Psychology, 33(4), 650-661. [xv] Foster, E.M., & Jones, D. (2006). Can a costly intervention be cost-effective?: An analysis of violence prevention [Abstract]. Archives of General Psychiatry, 63(11), 1284-1291. [xvi] Kumpfer, K.L., Alvarado, R., & Whiteside, H.O. (2003). Family-based interventions for substance use and misuse prevention. Substance Use and Misuse, 38(11-13), 1759-1787. [xvii] Roe, S., & Becker, J. (2005). Drug prevention with vulnerable young people: A review. Drugs: education, prevention and policy, 12(2), 85-99. [xviii] Kumpfer, K.L., Alvarado, R., & Whiteside, H.O. (2003). Family-based interventions for substance use and misuse prevention. Substance Use and Misuse, 38(11-13), 1759-1787. [xix] ibid [xx] Dewit, D. (n/d). Strengthening Families for the Future. Executive Summary of Outcome Evaluation. [xxi] Webster-Stratton, C., & Taylor, T. (2001). Nipping early risk factors in the bud: Preventing substance abuse, delinquency, and violence in adolescence through interventions targeted at young children (0–8 Years). Prevention Science, 2(3). [xxii] ibid [xxiii] Roe, S., & Becker, J. (2005). Drug prevention with vulnerable young people: A review. Drugs: education, prevention and policy, 12(2), 85-99. [xxiv] DeWit, D.J., Steep, B., Silverman, G., Stevens-Lavigne, A., Ellis, K., & Smythe, C. (2000). Evaluating an in-school drug prevention program for at-risk youth. The Alberta Journal of Education Research, 2, 117-133. [xxv] Eggert, L.L., Thompson, E.A., Herting, J.R., Nicholas, L.J., & Dicker, B.G. (1994). Preventing adolescent drug abuse and high school dropout through an intensive school-based social network development program. American Journal of Health Promotion, 8(3), 202-215. [xxvi] Cho, H., Hallfors, D.D., & Sanchez, V. (2005). Evaluation of a high school peer group intervention for at-risk youth. Journal of Abnormal Child Psychology, 33(3), 363–374. [xxvii] Stewart, S.H., Conrod, P.J., Allan, G., Marlatt, M., Comeau, N., Thush, C., & Krank, M. (2005). New developments in prevention and early intervention for alcohol abuse in youths. Alcoholism: Clinical and Experimental Research, 29(2). [xxviii] Mushquash, C.J., Comeau, M.N., & Stewart, S.H. (2007). An alcohol abuse early intervention for First Nations adolescents. The First Peoples Child and Family Review, 3, 17-26. [xxix] Hawkins, E., Cummins, L.H., & Marlatt, G. (2004). Preventing substance abuse in American Indian and Alaska native youth: Promising strategies for healthier communities. Psychological Bulletin, 130, 304–323. [xxx] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf [xxxi] Foxcroft, D., Ireland, D.J., Lister-Sharp, D., Lowe, G., & Breen, R. (2003). Longer-term primary prevention for alcohol misuse in young people: A systematic review. Addiction, 98, 397-411. [xxxii] Toumbourou, J.W., Stockwell, T., Neighbors, C., Marlatt, G.A., Sturge, J., Rehm, J. (2007). Interventions to reduce harm associated with adolescent substance use: An international review. Lancet, 369, 1391-1401. [xxxiii] Wilson, D.B., Gottfredson, D.C., & Najaka, S.S. (2001). School-based prevention of problem behaviors: A meta-analysis. Journal of Quantitative Criminology, 17(3). [xxxiv] Vasilaki, E.I., Hosier, S.G., & Cox, W.M. (2006). The efficacy of motivational interviewing as a brief intervention for excessive drinking: A meta-analytic review. Alcohol and Alcoholism, 41(3), 328-35. [xxxv] Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change [2nd ed.]. New York: Guilford Press. [xxxvi] Toumbourou, J.W., Stockwell, T., Neighbors, C., Marlatt, G.A., Sturge, J., & Rehm, J. (2007). Interventions to reduce harm associated with adolescent substance use: An international review. Lancet, 369, 1391-1401. [xxxvii] Tait, R.J., & Hulse, G.K. (2003). A systematic review of the effectiveness of brief interventions with substance using adolescents by type of drug. Drug and Alcohol Review, 22, 337-346 (Abstract). [xxxviii] Winters, K.C., Leitten, W., Wagner, E., O'Leary Tevyaw, T. (2007). Use of brief interventions for drug abusing teenagers within a middle and high school setting. The Journal of School Health, 77(4). [xxxix] Baer, J.S., Kivlahan, D.R., Blume, A.W., McKnight, P., & Marlatt, G.A. (2001). Brief intervention for heavy-drinking college students: 4-year follow-up and natural history. American Journal of Public Health, 91(8), 1310–1316. [xl] Comeau, N., Stewart, S.H., & Loba, P. (2001). The relations of trait anxiety, anxiety sensitivity, and sensation seeking to adolescents' motivations for alcohol, cigarette, and marijuana use. Addictive Behaviors, 26, 803-825. [xli] Conrod, P., Stewart, S., Comeau, N., & Maclean, A.M. (2006). Efficacy of cognitive–behavioral interventions targeting personality risk factors for youth alcohol misuse. Journal of Clinical Child and Adolescent Psychology, 35(4), 550-563. [xlii] Mushquash, C.J., Comeau, M.N., & Stewart, S.H. (2007). An alcohol abuse early intervention for First Nations adolescents. The First Peoples Child and Family Review, 3, 17-26. [xliii] ibid
Interactive teaching/learning methods
Targeted curriculum and services for higher risk students An excerpt from "School-based and school-linked prevention of substance use problems: A knowledge summary", Canadian Association for School Health, 2008. Universal drug education curricula have been criticized for having insufficient focus and intensity to effectively address the needs of higher risk youth. Studies of the effect of universal programs on substance-using youth have shown either no effect or an increase in use.[i] [ii] Youth may be considered higher risk on the basis of the accumulation of risk factors they are living with or on the basis of already engaging in early, hazardous substance use. Some researchers and programmers group these populations together as “targeted” populations; others distinguish between them, referring to “Selective” prevention for those living with various risk factors (e.g. family and school factors), and “Indicated” prevention for those using substances in a hazardous way, but not at the level of dependency. Because there is significant overlap between these two populations during adolescence (i.e. adolescents with a number of risk factors tend to use substances more hazardously) and the evaluation research does not define these areas of risk in a consistent way, this review will group all programming directed to at-risk students together but specify the characteristics of the target group as closely as possible.
It has been suggested that the young people who benefit from targeted programming are those who present a “life course deviance” profile (as opposed to adolescence-limited).[iii] [iv] They have often experienced a range of challenges in earlier childhood as summarized in Section IV. Early substance use is considered an important risk factor for ongoing problems (e.g., school truancy and drop-out, theft, violence, heightened sexual activity, substance dependence and suicide), but the early use is itself usually an outgrowth of earlier factors. Consequently, while programming in early adolescence when unhealthy behaviours may be forming is called for, so too is programming earlier in the life course when risk factors may be more amenable to change.[v]
Early childhood/elementary level multi-component programs
Because of the length of the follow-up period, only a few studies have assessed effects of elementary level programming on later substance use, but those few have generally produced positive results on substance use outcomes.[vi] [vii] These early school interventions do not pay direct attention to substance use but rather aim to improve educational environments, reduce social exclusion and aggressive and disruptive behaviour.[viii] [ix] Notably, they almost always have more than one component. Apparently central to the success of these programs is the school-parent partnership that leads parents and teachers to feeling more supported in their efforts and results in more success than those that target either teachers or parents or children alone.[x] As is often the case with multi-component interventions, the extent to which each component is responsible for the behaviour change is not clear for these interventions.
Well designed targeted pre and early school programming can have long-term impact on a range of problem behaviours.[xi] In what would be regarded in the context of this report as a “school-linked” program, the well-known High/Scope Perry Preschool Program (Michigan) showed enduring impact. This randomized study followed at-risk children to age 40 and found that those receiving a daily high quality (including low child-teacher ratio) 2.5 hour class in addition to weekly family visits for two pre-school years obtained positive life-long benefits in a range of life areas, including academic achievement, income, criminal activity and substance use, when compared to controls.[xii] While intensive, the program demonstrated cost effectiveness (see Section V. F.).
The Montreal Longitudinal Experimental Study for high-risk boys included classroom social-cognitive skills training and a home-based parent training program over two years (ages 7-9). Tremblay and colleagues identified 366 disruptive boys at age 6, and randomly assigned them to experimental and control conditions. The boys in the experimental condition received school-based training to foster social skills and self-control. Coaching, peer modeling, role playing, and reinforcement were used in small group sessions on topics such as, “What to do when you are angry” and “How to react to teasing.” Also, their parents were trained at home approximately once every 3 weeks over a 2-year span. (The average number of sessions was 17.4.) The combination of parent and child training for these high-risk children in kindergarten and first grade reduced rates of delinquency and school adjustment problems at age 12. By age 12, the boys in the experimental condition were less likely to get drunk, committed less theft, were less likely to be involved in fights and had higher achievement than controls. The program also demonstrated a snowball effect in that the differences between the experimental and control boys increased as time went on.[xiii]
In the U.S., researchers with the Fast Track project are studying the effects of a multi-component school and family intervention to shift the trajectory of children considered to be at high risk for later anti-social and problematic behaviours. Fast Track is a randomized, controlled trial that distributed 891 children from 55 schools between intervention and control conditions. The theoretic underpinning of this trial is that aggressiveness is an important risk factor for a number of later academic and social problems and that it arises from a mix of individual, family and school factors that cluster, interact and amplify each other in some children (for example, disruptive temperament in early childhood and weak parenting practices have the effect of aggravating and worsening each other). This large trial identified children in kindergarten who were beginning to show signs of disruptive behaviour at home and school, and provided a mix of family and school interventions from Grade 1 through to Grade 10 with heavier programming in the first two years of elementary school and at the transition to middle school. Interventions included parent training, home visits, children’s social skills groups, peer-pairing sessions and a universal social skills development curriculum; the aim was to improve relationships with parents during the early primary school years, and (starting in grade 1) improve home-school relations, and the child’s social problem solving, peer relations, school bonding and academic performance. The ultimate goals are to reduce various problematic behaviours (e.g. violent and aggressive behaviour, substance use, delinquency, risky sexual behaviour, and mental health problems) during adolescence and into adulthood.
The latest reported follow ups (end of grade 5) showed improvements in social functioning, deviant peer involvement, and serious antisocial behaviour in their home and community, but notably did not have an effect on academic performance or school behaviour. It remains to be seen whether the relatively small effects seen in these areas of functioning will have an impact on later substance use.[xiv] The program had much more effect on higher risk children with fewer than half as many cases of conduct disorder diagnosed in the intervention group as in the control group at grade 5. A discussion of program costs vs. costs of crime and delinquency concluded that the program was cost-effective in reducing conduct disorder and delinquency, but only for those who were very high-risk as young children.[xv]
Best advice 8: organize targeted elementary school programming to help parents and teachers impart basic personal and social skills to higher risk children; this programming can help students learn and prevent later problem behaviours, including hazardous substance use.
School-linked targeted family programs
It appears that “family-based” interventions are more effective than “parent-only” or “child only” programming in building protective factors and reducing substance use.[xvi] For example, the Focus on Family Program, consisting of parent skill building without an intervention for children showed no effect on children’s substance use.[xvii] Typically, effective family programming aims to build relationship and communication skills separately among the parents and the children, along with opportunities to learn and practice skills as a family unit. These programs have shown positive effects on a number of risk and protective factors and have brought about reductions in youth substance use. The provision of transportation, food and childcare during sessions, as well as advocacy and crisis support programs increase the likelihood of attracting and retaining families and are considered important elements of these programs.[xviii]
The Strengthening Families Program (SFP) is a well-replicated example of a family program that has been shown to be effective with targeted as well as universal populations (See Section D, Comprehensive Whole School Approaches). The program involves whole families coming together in a school, community centre, or other public place. The format for each week of the 14 session SFP involves parents and children first participate in skill-building activities after which families come together to practice the skills (e.g. communication and conflict-resolution skills). Free meals, transportation, and childcare are provided.
The SFP has been evaluated in several randomized control trials over a five-year follow-up period. The results showed that, compared with the control group, children in the experimental groups were significantly less likely to use substances and engage in other adolescent problem behaviours. The program has been adapted with positive results for lower risk families, families with older children and families of various cultural backgrounds.[xix]
A recent adaptation involved a three-year multi-site randomized controlled trial with Ontario families (along with families in New York State) recently affected by alcohol problems. To be eligible for the study, parents must have had an alcohol problem in the past five years and primary parenting responsibility for a child age 9-12 years. Over the 14-week period, the Ontario SFP families met once a week in the evening for three hours. The program contained four components: dinner hour, Child Skills Training Program, Parent Skills Training Program, and Family Skills Training Program. Four trained facilitators delivered the program sessions (two in the parent session and two in the child session). SFP participants also attended a two-hour booster session delivered immediately after the first study follow-up assessment designed to reinforce the skills taught in the 14-week program. In addition to the assessment immediately following the program, families were assessed at 4 months and 12 months after program completion. The control group received the Parent Intervention Program which comprised written material on parenting and local contact information. Although the trial has not published its results, the author has reported immediate and sustained positive effects for several family and child psychosocial outcomes, including: improved family functioning, more effective parenting techniques, reduced parent hostility and aggression, reduced symptoms of parent depression, reductions in children’s externalizing behaviour problems, better child social skills and better child coping skills. SFP children also displayed a 37% reduction in alcohol sipping relative to controls.[xx]
A review of targeted family programs has concluded that effective programs:[xxi]
- take a skills enhancing perspective;
- have broad-based content; program content includes cognitive, behavioural, and affective components;
- have a program length typically greater than 20 hours for children and families at elevated risk of developing problems;
- intervene as early as the risk factors can be clearly identified;
- are developmentally focused. (i.e., targeted at specific ages);
- use a collaborative process with parents, teachers, and children; ·
- focus on parents’ and children’s strengths (not deficits); ·
- utilize performance training methods; for example, programs that utilize videotape methods, live modeling, role-play or practice exercises, and weekly home practice activities are more effective than programs relying on didactic presentations;
- educate participants not only in strategies, but also in the developmental and behavioural principles behind them;
- promote partnerships between parents and teachers;
- emphasize the clinical skills of the intervention staff;
- are sensitive to barriers for low socioeconomic families and are culturally sensitive;
- have been empirically validated in control and comparison group studies using multiple methods and provide follow-up data.
Best advice 9: consider family skills programs to help higher risk families with elementary age children improve relationship skills; these programs can contribute significantly to family and child health and prevent later youth substance use.
Middle/high school programs
The most commonly evaluated approach to working with at-risk pre- and early adolescent youth is school-based life-skills programming.[xxiii] Programs targeting young at-risk adolescents in transition school years have been evaluated in Canada and the U.S. Ontario’s Opening Doors program by DeWitt and colleagues (2000) assessed an in-school program aimed at preventing or reducing drug use and other deviant behaviour in high-risk young people during their transition from Grade 8 to 9.[xxiv]
Opening Doors selected high-risk students using a screening test assessing demographic and behavioural characteristics. The program consisted of two separate program components running concurrently – a student program and a parent program. The student program consisted of instruction using a social skills training approach and a peer support component. Seventeen sessions of approximately one hour in length were offered once or twice weekly over a 10-week period. Through group activities and discussion the program aimed to help students develop personal and social skills to enhance their school experience and relationship with peers, teachers, and parents. The program was intended to accommodate 10 to 12 students at a time.
The parent program consisted of five evening sessions of approximately two hours in length held on alternate weeks over the duration of the student program. It was intended to foster a positive home environment in which parents actively support and reinforce their children's school experience. It was hoped that improved parent-child interactions, better management of their children's behavioural problems, and reinforcement and support of the student program would contribute to a reduction of the prevalence and frequency of substance abuse, school drop-out, violent and other antisocial behaviour, and an improvement in academic achievement. Participants in the experimental group showed several behavioural improvements immediately following the program; the effects had eroded by the 6-month follow-up, but were still somewhat in evidence relative to the comparison group. The Opening Doors program is similar to the Reconnecting Youth program tested and widely disseminated in the U.S. In the Reconnecting Youth program, students at risk of dropping out of Grades 9 to 12 were offered “personal growth classes”, small classes offering group support, friendship development, and school bonding. A specific skills training course was also offered based on four units: self-esteem enhancement, decision making, personal control, and interpersonal communication. Those receiving the program reported improvements in school bonding, self-esteem and reductions in deviant peer associations and were less likely to initiate substance use. However, the design of the study was relatively weak and reviewers have called for more rigorous evaluation of this program.[xxv]
Cho et al (2005) replicated the Reconnecting Youth program using a stronger study design and failed to demonstrate positive findings. In fact, at follow-up there were indications of the experimental group doing more poorly than the controls, and the authors raised the possibility that “deviancy training” had occurred among the high-risk youth in the experimental group. As the authors noted, “Clustering high-risk students in the Reconnecting Youth classroom setting provides a consistent opportunity to affiliate and bond with deviant peers and removes the opportunity to spend that time in a regular class with more conventional peers” (p. 371).[xxvi] Until further light is shed on this question, schools should carefully consider the potential for harm when selecting groups of at-risk middle or high school students for special programming.
Programs for Aboriginal students
Because relevance is important in all programming, culturally appropriate substance education programming is likely to increase the potential of programs for First Nations students. However, using Aboriginal culture as simply an “add on” to program content creates only vague awareness of cultural issues. The integration of both Aboriginal content and perception entails a deeper understanding of cultural values, practices and symbols.[xxvii] [xxviii] It also means recognizing that Aboriginal students are not a homogeneous population and can vary greatly in their perspective according to geography and location (e.g. reserve or urban).
In their review of programming for Native American adolescents, Hawkins and colleagues found bi-cultural competence approaches to skills training to be most promising for reducing prevalence of drug use in Native American youth.[xxix] This approach aims to equip young people with coping skills to negotiate between mainstream and Aboriginal cultures.[xxx] In addition to coping skills training, the process of respectful relationship building (i.e., caring and sharing) with teachers, role models and Elders can profoundly influence a young person’s sense of belonging to their community and to society.
Schinke and colleagues (2000) reported a long-term follow-up of a culturally-focused school and community intervention with about 1,400 Native American students in 27 schools in the U.S. Two interventions were tested against a control condition: a school-based skills development program, and the skills plus a community involvement program. Youths in schools assigned to the control arm did not receive any intervention. Students in Grades 3-5 received 15 50-minute weekly sessions that combined conventional cognitive-behavioural skills development with culturally tailored content and activities. Cultural content addressed substance use issues and holistic concepts of health and health promotion among Native people. In the context of culturally specific situations, youths acquired new skills by applying them initially to role-play situations, then subsequently to situations volunteered by youths from their daily lives. The program included exercises that increased students’ awareness of Native cultural traditions that run counter to substance abuse. Every session included homework assignments for youths to gather information and testimonies on relevant topics. The school plus community involvement component aimed at reinforcing the skills developed in school. Substance prevention awareness messages were presented through a number of channels, including the students’ families, teachers and school guidance counsellors, neighbourhood residents, law enforcement officials, and commercial establishments frequented by youths. Flyers and posters were distributed to businesses, health and social service agencies, schools, and churches. Informational meetings were also held for parents, neighbours, and teachers, informing them about intervention components youths were receiving. Informational sessions took place at local schools and included poster-making exercises, mural painting, skits, and problem-solving contests. Semi-annually, students in the two intervention arms received two 50-minute sessions booster sessions.
At the 3.5 year follow-up, both the students in the curriculum and curriculum + community arm were using alcohol and cannabis at a lower rate than the control students; neither intervention had any effect on cigarette use. Notably, the students in the curriculum arm were using these substances at a lower rate than those participating in the curriculum + community arm, which runs counter to accepted wisdom. This interesting finding could reflect networks of communication in a collective society, i.e., extended family culture and its influence on peer support could have impacted the behavioural choices of students participating only in the curriculum. The study reported gender differences and found that boys were more likely to have high rates of alcohol use, while girls were more likely to use cigarettes regularly, and there was little difference with cannabis use. In his Cochrane review, Foxcroft (2003) concluded that this approach is one of the more promising approaches in the adolescent alcohol prevention literature.[xxxi]
Best advice 10: for Aboriginal students, deliver substance education that employs a bi-cultural competence approach to equip students with skills to cope effectively in mainstream and Aboriginal cultures; this approach calls for ongoing trust building and collaboration between schools, public health and Elders and other respected Aboriginal leaders.
Brief interventions
For populations using substances hazardously but who aren’t necessarily dependent, brief interventions employing cognitive-behavioural and/or motivational principles are increasingly used. These approaches, having shown substantial promise for addressing hazardous use of alcohol, tobacco, and other drugs with a range of populations and settings,[xxxii] [xxxiii] [xxxiv] are increasingly being evaluated for the secondary school setting. Cognitive-behavioural approaches focus on methodically building skills to deal with current issues of the client/student. These approaches often include an assessment of the current situation followed by identification of personalised, usually time-limited goals and strategies which are monitored and evaluated. The approach is inherently empowering in nature, the outcome being to focus on acquiring and utilising new skills, with an emphasis on putting what has been learned into practice between sessions through homework. Motivational interviewing, developed by Miller and Rollnick is a person-centered interviewing style with the goal of resolving conflicts regarding the pros and cons of change, enhancing motivation, and encouraging positive changes in behaviour. The interviewer’s style is characterised by empathy and acceptance, with an avoidance of direct confrontation. Any statements about positive behaviour change brought up by the person in the discussion are encouraged to support self-efficacy and a commitment to take action.[xxxv]
There is no consensus on what constitutes a “brief” intervention. Interventions may range from four sessions to 5 min to receipt of one or more feedback sheets in the mail. They are often conducted by a health professional in which case a screening instrument is used to identify those using substances at hazardous levels (for example, the Rutgers Alcohol Problem Index (RAPI), which includes questions designed to assess consequences of problems, such as hangovers, cognitive impairment, and interpersonal conflict).[xxxvi] However because hazardous drinkers are often reluctant to discuss their drinking with a doctor or other practitioner, online self-assessment followed by brief intervention in the form of personalized feedback about one’s drinking has been found to be a popular intervention strategy among younger people.
There is some indication that targeted programming using these formats may be more effective for higher-risk adolescents than universal programs, but the evidence base is small because few programs have been rigorously evaluated. The meta-analysis by Gottfredson and Wilson (2003) found that cognitive-behaviourally oriented programs were more effective for higher-risk youth than others, but they called for more study in this area before drawing firm conclusions. In their review of brief interventions for adolescents, Tait and Hulse (2003) found that brief interventions directed to adolescents were effective across a diverse range of settings (dental clinics, schools, universities, substance treatment centres) and, therefore, probably diverse clients. Most of the interventions reviewed drew on motivational principles; those focusing on alcohol had a small effect, and those addressing tobacco had no effect, while the effect for the few concerned with multiple substances appeared substantial, but the sample was too small to generalize broadly.
Although the size of the effect for these interventions tends to be modest, it needs to be weighed against the amount of contact time involved.[xxxvii] In a review and discussion of school-based brief interventions, Winters and colleagues (2007) did not identify any actually set in schools; they found 3 studies of brief interventions for adolescents based in other settings, all of which showed modest results.[xxxviii]
At the post-secondary level, brief interventions (including online versions) have been found effective in reducing alcohol-related harms, and may have application in senior high school settings. One example is the Brief Alcohol Screening in College Students (BASICS) program which has been found effective in reducing binge and excessive drinking in college students in several long-term follow-up studies. BASICS consists of two one-on-one interviews designed to promote reduced alcohol consumption or abstinence among high-risk drinkers. The format consists of personalised feedback, including descriptive graphs presenting the person’s own drinking patterns in relation to normative trends, negative consequences of drinking, and related attitudes and beliefs. An attempt is made to resolve ambivalence about changing one’s drinking behaviour and to move toward a safer drinking plan.[xxxix]
A promising example of a brief intervention for alcohol problems in the secondary school setting has been rigorously tested in this country. Conrod, Stewart, Comeau and MacLean conducted a randomized controlled trial of the effect of a brief intervention targeting one of three personality profiles: anxiety sensitivity (AS), hopelessness (H), and sensation seeking (SS) in high schools in urban British Columbia and rural Nova Scotia.[xl] [xli] Students were randomly assigned to the appropriate personality intervention or to a no-treatment control group at each site and then reassessed 4 months later. All participating students had consumed alcohol in the previous 4 months; they were viewed as not yet having demonstrated significant drinking problems but at risk for doing so based on their personalities. Interventions were delivered by therapists and research assistants and consisted of two 90-minute sessions spread across 2 weeks; the number of students per group ranged from 2 to 7.
Each intervention incorporated principles from the motivational and cognitive–behavioural literatures. The three main components of the interventions were (a) psycho-education, (b) behavioural coping skills training, and (c) cognitive coping skills training. The interventions began with the psycho-educational component – girls and boys were educated about the personality variable in question and the problematic coping behaviours associated with that personality style. Students were encouraged to discuss the short-term reinforcing properties of a variety of problematic coping strategies (including alcohol use) to help them understand their specific motivations for engaging in problematic and risky behaviours. This was followed by a motivational intervention (weighing the short- and long-term positive and negative consequences of a particular behaviour) around the use of problematic behavioural strategies for coping with that particular personality dimension. Next, cognitive coping skills training helped students learn how to identify and challenge cognitive distortions specific to each personality, using stories and exercises from students’ lives.
These brief interventions led to significantly better outcomes compared to the control group students as measured by rates of abstinence, reduced drinking quantity, binge drinking rates, and alcohol problems. Interestingly, the intervention appeared to have effects on aspect of drinking behaviour particularly linked to each of the personality types. For example, the sensation-seeking group was more likely to engage in binge drinking than the other two personality groups, and the intervention appeared to have more impact on this drinking variable for the sensation-seeking group than the other two groups. The outcomes for this three-hour intervention were quite promising at four months and demonstrate the potential of a well targeted intervention, but it will be important to determine whether the effects are maintained over a longer period, and to replicate findings.
It will also be interesting to learn whether a sustainable delivery format can be found, given that this trial was conducted by specifically trained therapists. A bi-cultural competence approach has also been shown to be effective within a brief intervention program for Aboriginal youth which similarly targets personality and motivational factors.[xlii] Recent community collaboration led to the development and testing of a culturally relevant brief intervention program for First Nation youth in Nova Scotia designed to address the issue of alcohol abuse and prevention of alcohol problems among Mi’maq adolescents. The pilot results were positive in that compared to pre-intervention, students who participated in the intervention drank less, engaged in less binge-drinking episodes, had fewer alcohol-related problems, were more likely to abstain from alcohol use, and reduced their marijuana use at four-months post-intervention. No such significant changes were observed in a non-random group of eligible students who did not participate in the intervention. Future research should determine if the methodology for development of a similar intervention is effective for at-risk youth in other Aboriginal communities across Canada, and whether the promising, but preliminary results with marijuana mean that the benefits of the intervention might extend to adolescents’ use of substances other than alcohol. This 2 x 90 minute program was delivered in a sustainable format through the training of local First Nation school guidance counsellors and police officers as co-facilitators.[xliii]
Best advice 11: with at-risk students (including Aboriginal students), consider school-based brief interventions (fewer than 4 sessions); these interventions, when guided by principles of recognition, respect, sharing, and responsibility, have been found to promote abstinence and reduced hazardous drinking and alcohol problems.
End Notes
[i] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf [ii] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38. [iii] Spooner, C., & Heatherington, K. (2004). Social determinants of drug use [Tech. Rep. No. 228]. Retrieved September 30, 2007, from http://ndarc.med.unsw.edu.au/ndarcweb.nsf/website/Publications.reports.TR228 [iv] Toumbourou, J.W., Rowland, B., Jefferies, A., Butler, H., & Bond, L. (2004). Preventing drug-related harm through school re-organisation and behavior management [Prevention research evaluation report No. 12]. Melbourne, Australia: Australia Drug Foundation. Retrieved September 30, 2007, from http://www.druginfo.adf.org.au/downloads/Prevention_Research_Quarterly/PRQ_04Nov_Early_intervention_in_schools.pdf [v] ibid [vi] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38. [vii] Toumbourou, J.W., Stockwell, T., Neighbors, C., Marlatt, G.A., Sturge, J., & Rehm, J. (2007). Interventions to reduce harm associated with adolescent substance use: An international review. Lancet, 369, 1391-1401. [viii] Webster-Stratton, C., & Taylor, T. (2001). Nipping early risk factors in the bud: Preventing substance abuse, delinquency, and violence in adolescence through interventions targeted at young children (0–8 Years). Prevention Science, 2(3). [ix] Toumbourou, J.W., Stockwell, T., Neighbors, C., Marlatt, G.A., Sturge, J., & Rehm, J. (2007). Interventions to reduce harm associated with adolescent substance use: An international review. Lancet, 369, 1391-1401. [x] Webster-Stratton, C., & Taylor, T. (2001). Nipping early risk factors in the bud: Preventing substance abuse, delinquency, and violence in adolescence through interventions targeted at young children (0–8 Years). Prevention Science, 2(3). [xi] Foley, D., Goldfeld, S., McLoughlin, J., Nagorcka, J., Oberklaid, F., & Wake, M. (2000). A review of the early childhood literature. Retrieved September 30, 2007, from http://www.facs.gov.au/internet/facsinternet.nsf/vIA/families/$file/early_childhood.pdf [xii] Schweinhart, L.J. (2004). The High/Scope Perry Preschool study through age 40. Summary, conclusions, and frequently asked questions. Retrieved September 30, 2007, from http://www.highscope.org/file/Research/PerryProject/3_specialsummary%20col%2006%2007.pdf [xiii] Webster-Stratton, C., & Taylor, T. (2001). Nipping early risk factors in the bud: Preventing substance abuse, delinquency, and violence in adolescence through interventions targeted at young children (0–8 Years). Prevention Science, 2(3). [xiv] Conduct Problems Prevention Research Group. (2004). The Effects of the Fast Track Program on Serious Problem Outcomes at the End of Elementary School. Journal of Clinical Child and Adolescent Psychology, 33(4), 650-661. [xv] Foster, E.M., & Jones, D. (2006). Can a costly intervention be cost-effective?: An analysis of violence prevention [Abstract]. Archives of General Psychiatry, 63(11), 1284-1291. [xvi] Kumpfer, K.L., Alvarado, R., & Whiteside, H.O. (2003). Family-based interventions for substance use and misuse prevention. Substance Use and Misuse, 38(11-13), 1759-1787. [xvii] Roe, S., & Becker, J. (2005). Drug prevention with vulnerable young people: A review. Drugs: education, prevention and policy, 12(2), 85-99. [xviii] Kumpfer, K.L., Alvarado, R., & Whiteside, H.O. (2003). Family-based interventions for substance use and misuse prevention. Substance Use and Misuse, 38(11-13), 1759-1787. [xix] ibid [xx] Dewit, D. (n/d). Strengthening Families for the Future. Executive Summary of Outcome Evaluation. [xxi] Webster-Stratton, C., & Taylor, T. (2001). Nipping early risk factors in the bud: Preventing substance abuse, delinquency, and violence in adolescence through interventions targeted at young children (0–8 Years). Prevention Science, 2(3). [xxii] ibid [xxiii] Roe, S., & Becker, J. (2005). Drug prevention with vulnerable young people: A review. Drugs: education, prevention and policy, 12(2), 85-99. [xxiv] DeWit, D.J., Steep, B., Silverman, G., Stevens-Lavigne, A., Ellis, K., & Smythe, C. (2000). Evaluating an in-school drug prevention program for at-risk youth. The Alberta Journal of Education Research, 2, 117-133. [xxv] Eggert, L.L., Thompson, E.A., Herting, J.R., Nicholas, L.J., & Dicker, B.G. (1994). Preventing adolescent drug abuse and high school dropout through an intensive school-based social network development program. American Journal of Health Promotion, 8(3), 202-215. [xxvi] Cho, H., Hallfors, D.D., & Sanchez, V. (2005). Evaluation of a high school peer group intervention for at-risk youth. Journal of Abnormal Child Psychology, 33(3), 363–374. [xxvii] Stewart, S.H., Conrod, P.J., Allan, G., Marlatt, M., Comeau, N., Thush, C., & Krank, M. (2005). New developments in prevention and early intervention for alcohol abuse in youths. Alcoholism: Clinical and Experimental Research, 29(2). [xxviii] Mushquash, C.J., Comeau, M.N., & Stewart, S.H. (2007). An alcohol abuse early intervention for First Nations adolescents. The First Peoples Child and Family Review, 3, 17-26. [xxix] Hawkins, E., Cummins, L.H., & Marlatt, G. (2004). Preventing substance abuse in American Indian and Alaska native youth: Promising strategies for healthier communities. Psychological Bulletin, 130, 304–323. [xxx] McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews [Evidence briefing update]. Retrieved September 30, 2007, from http://www.nice.org.uk/niceMedia/docs/drug_use_prev_update_v9.pdf [xxxi] Foxcroft, D., Ireland, D.J., Lister-Sharp, D., Lowe, G., & Breen, R. (2003). Longer-term primary prevention for alcohol misuse in young people: A systematic review. Addiction, 98, 397-411. [xxxii] Toumbourou, J.W., Stockwell, T., Neighbors, C., Marlatt, G.A., Sturge, J., Rehm, J. (2007). Interventions to reduce harm associated with adolescent substance use: An international review. Lancet, 369, 1391-1401. [xxxiii] Wilson, D.B., Gottfredson, D.C., & Najaka, S.S. (2001). School-based prevention of problem behaviors: A meta-analysis. Journal of Quantitative Criminology, 17(3). [xxxiv] Vasilaki, E.I., Hosier, S.G., & Cox, W.M. (2006). The efficacy of motivational interviewing as a brief intervention for excessive drinking: A meta-analytic review. Alcohol and Alcoholism, 41(3), 328-35. [xxxv] Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change [2nd ed.]. New York: Guilford Press. [xxxvi] Toumbourou, J.W., Stockwell, T., Neighbors, C., Marlatt, G.A., Sturge, J., & Rehm, J. (2007). Interventions to reduce harm associated with adolescent substance use: An international review. Lancet, 369, 1391-1401. [xxxvii] Tait, R.J., & Hulse, G.K. (2003). A systematic review of the effectiveness of brief interventions with substance using adolescents by type of drug. Drug and Alcohol Review, 22, 337-346 (Abstract). [xxxviii] Winters, K.C., Leitten, W., Wagner, E., O'Leary Tevyaw, T. (2007). Use of brief interventions for drug abusing teenagers within a middle and high school setting. The Journal of School Health, 77(4). [xxxix] Baer, J.S., Kivlahan, D.R., Blume, A.W., McKnight, P., & Marlatt, G.A. (2001). Brief intervention for heavy-drinking college students: 4-year follow-up and natural history. American Journal of Public Health, 91(8), 1310–1316. [xl] Comeau, N., Stewart, S.H., & Loba, P. (2001). The relations of trait anxiety, anxiety sensitivity, and sensation seeking to adolescents' motivations for alcohol, cigarette, and marijuana use. Addictive Behaviors, 26, 803-825. [xli] Conrod, P., Stewart, S., Comeau, N., & Maclean, A.M. (2006). Efficacy of cognitive–behavioral interventions targeting personality risk factors for youth alcohol misuse. Journal of Clinical Child and Adolescent Psychology, 35(4), 550-563. [xlii] Mushquash, C.J., Comeau, M.N., & Stewart, S.H. (2007). An alcohol abuse early intervention for First Nations adolescents. The First Peoples Child and Family Review, 3, 17-26. [xliii] ibid
Interactive teaching/learning methods
This page discusses teaching and learning methods and strategies that are more effective in preventing subtance abuse and other addictive behaviours.
The element of drug education programs with the strongest base of research support is student interactivity,[i] [ii] [iii] [iv] having been found to be 2-4 times more effective than non-interactive programs.[v] Tobler and Stratton’s meta-analysis (1997) provided useful insight into the type of interactivity that is most effective. They found that programs emphasizing student-to-student, rather than student-to-teacher interaction, showed significantly more positive effects on student substance use. They assert that it is the structured and unstructured task-oriented peer interaction between classmates that is the important variable in effectiveness. In this process, students need to have the opportunity to interact in a small group context, to test out and exchange ideas on how to handle drug use situations and to gain peer feedback about the acceptability of their ideas in a safe environment. Tobler (2000) even goes so far as to suggest that it is the exchange of ideas and experiences between students, and the opportunity to practice new skills and to obtain feedback on skills practice that acts as a catalyst for change rather than any critical content of the program.
The role of the teacher/leader in these types of sessions is to set an open, non-judgmental atmosphere, manage the process as a facilitator (rather than as a presenter), and maximize the opportunity for peer interchange and skills practice. The teacher also plays an important role in correcting misperceptions that may arise, and in offering information as needed.[vi] The specific techniques that work well in this process are role-plays, Socratic questioning, simulations, brainstorming, cooperative learning, peer-to-peer discussion and service-learning projects.
The element of drug education programs with the strongest base of research support is student interactivity,[i] [ii] [iii] [iv] having been found to be 2-4 times more effective than non-interactive programs.[v] Tobler and Stratton’s meta-analysis (1997) provided useful insight into the type of interactivity that is most effective. They found that programs emphasizing student-to-student, rather than student-to-teacher interaction, showed significantly more positive effects on student substance use. They assert that it is the structured and unstructured task-oriented peer interaction between classmates that is the important variable in effectiveness. In this process, students need to have the opportunity to interact in a small group context, to test out and exchange ideas on how to handle drug use situations and to gain peer feedback about the acceptability of their ideas in a safe environment. Tobler (2000) even goes so far as to suggest that it is the exchange of ideas and experiences between students, and the opportunity to practice new skills and to obtain feedback on skills practice that acts as a catalyst for change rather than any critical content of the program.
The role of the teacher/leader in these types of sessions is to set an open, non-judgmental atmosphere, manage the process as a facilitator (rather than as a presenter), and maximize the opportunity for peer interchange and skills practice. The teacher also plays an important role in correcting misperceptions that may arise, and in offering information as needed.[vi] The specific techniques that work well in this process are role-plays, Socratic questioning, simulations, brainstorming, cooperative learning, peer-to-peer discussion and service-learning projects.
[i] Tobler, N.S., & Stratton, H.H. (1997). Effectiveness of school-based drug prevention programs: A meta-analysis of the research. The Journal of Primary Prevention, 18(1), 71-128.
[ii] Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27(6), 1009-1023.
[iii] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf
[iv] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[v] Tobler, N.S., & Stratton, H.H. (1997). Effectiveness of school-based drug prevention programs: A meta-analysis of the research. The Journal of Primary Prevention, 18(1), 71-128.
[vi] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
Teacher/leader qualities & attitudes
This page discusses the qualities, skills and attitudes necessary for effective drug education. Related topics include peer-led instruction, the use of external visitors for presentations and non-judgemental attitudes.
Teacher/leader qualities
While most evaluated programs have been led by teachers, many others, particularly peers, have also led programs. Gottfredson and Wilson (2003), in their meta-analysis of 94 drug education programs, found programs that were led by peers unassisted by teachers to be clearly more effective than teacher-led programs or programs co-led by teachers and peer leaders.[i]
The Tobler et al 1998 meta-analysis found mental health practitioners and peer leaders were superior to general classroom teachers, but not significantly.[ii] A common use of peer leaders is to lead the normative component of the program to enhance the believability of normative information on drug use.[iii] Often peer leaders gain greater benefit than classroom students from peer led programs.[iv] Cautions have been identified in using peer leaders, particularly the need for careful selection and training of appropriate leaders.[v] [vi] Peer programs also require more planning. Practical considerations include timetabling, peer training, peer leader absence, length of time between peer leader training and their use in the classroom, and any additional funding required to conduct such programs.[vii]
It is often concluded that drug education is best taught by classroom teachers due to: the challenges of sustaining a peer-led program; their having first-hand knowledge of students' needs and developmental level, being best placed to deliver (and if necessary to modify) program components at an appropriate time and level for their students.[viii]
The question of who delivers is quite possibly secondary to the question of what qualities are important for the person who delivers. It is speculated that mental health practitioners are effective because they have skills and training in facilitation and group process, for example creating a non-judgmental atmosphere, being comfortable in a non-directive role (e.g., with ambivalence, and with remaining silent to facilitate dialogue).
Regardless of who is delivering, best results can be expected from selecting teacher/leaders with these qualities, acquired through some mix of personal attributes and pre- or in-service training.[ix] Guest presenters are often considered for drug education sessions. Given this evidence, it is important that guest presenters be able to address curriculum objectives and work interactively with the students, rather than present an isolated session unconnected with the curriculum.[x] Newer interactive technologies (e.g., CD-ROM, DVD, Internet) to present or reinforce relevant knowledge and skills may be a useful adjunct to classroom prevention programs.[xi]
Teacher/leader qualities
While most evaluated programs have been led by teachers, many others, particularly peers, have also led programs. Gottfredson and Wilson (2003), in their meta-analysis of 94 drug education programs, found programs that were led by peers unassisted by teachers to be clearly more effective than teacher-led programs or programs co-led by teachers and peer leaders.[i]
The Tobler et al 1998 meta-analysis found mental health practitioners and peer leaders were superior to general classroom teachers, but not significantly.[ii] A common use of peer leaders is to lead the normative component of the program to enhance the believability of normative information on drug use.[iii] Often peer leaders gain greater benefit than classroom students from peer led programs.[iv] Cautions have been identified in using peer leaders, particularly the need for careful selection and training of appropriate leaders.[v] [vi] Peer programs also require more planning. Practical considerations include timetabling, peer training, peer leader absence, length of time between peer leader training and their use in the classroom, and any additional funding required to conduct such programs.[vii]
It is often concluded that drug education is best taught by classroom teachers due to: the challenges of sustaining a peer-led program; their having first-hand knowledge of students' needs and developmental level, being best placed to deliver (and if necessary to modify) program components at an appropriate time and level for their students.[viii]
The question of who delivers is quite possibly secondary to the question of what qualities are important for the person who delivers. It is speculated that mental health practitioners are effective because they have skills and training in facilitation and group process, for example creating a non-judgmental atmosphere, being comfortable in a non-directive role (e.g., with ambivalence, and with remaining silent to facilitate dialogue).
Regardless of who is delivering, best results can be expected from selecting teacher/leaders with these qualities, acquired through some mix of personal attributes and pre- or in-service training.[ix] Guest presenters are often considered for drug education sessions. Given this evidence, it is important that guest presenters be able to address curriculum objectives and work interactively with the students, rather than present an isolated session unconnected with the curriculum.[x] Newer interactive technologies (e.g., CD-ROM, DVD, Internet) to present or reinforce relevant knowledge and skills may be a useful adjunct to classroom prevention programs.[xi]
[i] Gottfredson, D.C., & Wilson, D.B. (2003). Characteristics of effective school-based substance abuse prevention. Prevention Science, 4(1), 27-38.
[ii] Tobler, N.S. (2000). Lessons learned. The Journal of Primary Prevention, 20(4), 261-274.
[iii] Skara, S., & Sussman, S. (2003). A review of 25 long-term adolescent tobacco and other drug use prevention program evaluations. Preventive Medicine, 37, 451-474.
[iv] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[v] Loxley, W., Toumbourou, J.W., & Stockwell, T. (2004). The prevention of substance use, risk and harm in Australia: A review of the evidence. Retrieved September 30, 2007, from http://www.aodgp.gov.au/internet/wcms/publishing.nsf/content/health-pubhlth-publicat-document-mono_prevention-cnt.htm
[vi] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf
[vii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[viii] McBride, N. (2003). A systematic review of school drug education. Health Education Research: Theory and Practice, 18(6), 729-742.
[ix] Hawks, D., Scott, K., & McBride, M. (2002). Prevention of psychoactive substance use: A selected review of what works in the area of prevention. Retrieved September 30, 2007, from http://www.who.int/entity/mental_health/evidence/en/prevention_intro.pdf
[x] Buckley, E.J., & White, D.G. (2007). Systematic review of the role of external contributors in school substance use education. Health Education, 107(1), 42-62.
[xi] Williams, C., Griffin, K.W., Macaulay, A.P., West, T.L., & Gronewold, E. (2005). Efficacy of a drug prevention CD-ROM intervention for adolescents. Substance Use and Misuse, 40(6), 869-878.
dmccall |
Latest page update: made by dmccall
, Mar 15 2011, 10:09 PM EDT
(about this update
About This Update
Rename
- dmccall
No content added or deleted. - complete history) |
|
More Info: links to this page
|
There are no threads for this page.
Be the first to start a new thread.
