Name of Organization: Alternatives for Youth. Project Title: Collaboration in Action: Innovative Treatment Services for Youth in Schools

Transcription

1 Name of Organization: Alternatives for Youth Project Title: Collaboration in Action: Innovative Treatment Services for Youth in Schools Project Lead: Sue Kennedy, Executive Director Project Summary: This project will provide a preliminary evaluation of a school-based mental health and addiction treatment for secondary students in the Hamilton-Wentworth region. Amount awarded: $20, Final report submitted: March 10, 2014 Region: MCYS region EPG

2 Table of Contents A. Executive Summary 3 B. Introduction and Literature Review 5 C. Methodology 9 D. Pilot Results 9 E. Stakeholder Involvement and Knowledge Exchange 11 F. Conclusion and Recommendations and Next Steps 12 G. References and Appendices 13 References Appendix A Program Logic Model Appendix B Client Satisfaction Questionnaire 2

3 A. Executive Summary Name of organization: Alternatives for Youth Project title: Collaboration in Action: Innovative Treatment Services for Youth in Schools Project Lead: Sue Kennedy, Executive Director Project Summary: The project will provide a preliminary evaluation of a school-based mental health and addiction treatment program for secondary students in the Hamilton-Wentworth region. The Purpose Background: Alternatives For Youth (AY) has been providing addictions and mental health treatment for students of the Hamilton Wentworth District School Board for over 20 years. This evaluation will highlight the partnership story and outcomes for students and the community. Objectives: Improve integrated services for students with addiction and mental health concerns, increase local capacity to support students, and to support system planning. Methods: The Hamilton-Wentworth District School Board implemented an addictions and mental health strategy as a result of identified needs. Alternatives for Youth responded by implementing increased education and treatment programs for students, parent education sessions, and coordinated community and school consultation. Results: Student outcomes: reduced substance use, increased awareness of the adverse effects of use on learning, personal functioning, and relationships. Outcomes for school staff: increased awareness of student substance use and mental health, screening, and treatment planning. Outcomes for the community: increased system planning and identification of community needs. Conclusions: Students are able to self-refer to treatment services when they are available on site. School staff is better equipped to support students when professional expertise, support, and consultation are available. Youth, their families, and community services have greater access to substance use and mental health support when schools are responsive to student and community needs. The Program Alternatives for Youth provide specialized school- based mental health and addiction counselling for secondary students. Comprehensive assessment and treatment planning ensures that students receive the necessary, specialized, and timely care that they require. Through a well-established and formal partnership with the Hamilton Wentworth District School Board, AY provides counselling services on-site at 8 secondary schools. In addition, AY provides linkages to more intensive mental health services upon assessment and throughout the course of treatment. In order to address the complexity of needs faced by youth suffering with a concurrent disorder AY counsellors provide referrals to psychiatric services, linking with primary care physicians, and providing aftercare support 3

4 and follow-up for students who have required intensive inpatient treatment. On-site school-based services create increased accessibility for youth, reduced wait-times, reduced no-shows, shared treatment planning with other service providers, and increased referrals and follow-up. The Plan Evaluation activities included the recruitment and training of the evaluation team and the recruitment of a social work student to coordinate the project. A preliminary evaluation plan and literature review was conducted and a logic model was developed. The evaluation framework and methods were determined. Best practices and evidence informed interventions were implemented. Non-identifying client data was collated from the agencies existing data base, and a client satisfaction tool was distributed. A knowledge exchange plan was developed and implemented. The Product The evaluation team engaged well with the project by participating in training webinars hosted by the Centre of Excellence resulting in an increased in knowledge and skill specific to evaluation processes and elements. The evaluation team met weekly to complete tasks within the required timelines. In addition agency staff consulted regularly with the Centre of Excellence research team. A Logic model, evaluation framework, and a client satisfaction tool were implemented. Preliminary findings indicate that students are engaged in their treatment process, confident to achieve their goals related to mental health and addiction, and have increased their knowledge and skill related to those goals. Knowledge Exchange activities included dissemination of findings to agency staff and Board of Directors, and partners and stakeholders through participation at community planning tables. Knowledge exchange activities included the application and acceptance of an abstract submission to the Canadian Centre of Substance Abuse National Conference held in Ottawa in November, The presentation generated an invitation from the Centre of Addiction and Mental Health to feature our program on the CAMH Evidence Exchange Network (EENET). In addition, over the course of the project, AY has been invited to participate in a provincial evaluation project funded by the Trillium foundation and an extended evaluation project funded by Health Canada s Drug Treatment Funding Program (pending approval) demonstrating the agencies readiness to engage in further evaluation initiatives. Amount awarded: $20, Final report submitted: March 10, 2014 Region: MCYS region EPG

5 B. Introduction and Literature Review Background: Alternatives For Youth (AY) has been providing addictions and mental health treatment for students of the Hamilton Wentworth District School Board for over 20 years. This evaluation will highlight the partnership story and outcomes for students and the community. Objectives: Improve integrated services for students with addiction and mental health concerns, increase local capacity to support students, and to support system planning. Methods: The Hamilton-Wentworth District School Board implemented an addictions and mental health strategy as a result of identified needs. Alternatives for Youth responded by implementing increased education and treatment programs for students, parent education sessions, and coordinated community and school consultation. Results: Student outcomes: reduced substance use, increased awareness of the adverse effects of use on learning, personal functioning, and relationships. Outcomes for school staff: increased awareness of student substance use and mental health, screening, and treatment planning. Outcomes for the community: increased system planning and identification of community needs. Conclusions: Students are able to self-refer to treatment services when they are available on site. School staff is better equipped to support students when professional expertise, support, and consultation are available. Youth, their families, and community services have greater access to substance use and mental health support when schools are responsive to student and community needs. Program Overview: Alternatives for Youth and the Hamilton-Wentworth District School Board (HWDSB) have a formal partnership for AY to provide counselling services to students and families for concerns related to substance use, including but not limited to drug awareness, education, and treatment. This service is available to students who voluntarily seek support, and also to students who have counselling as an alternative option to suspension. Services are carried out within the high school. Key activities of this program include the completion of screening and assessment of the client, the completion of a treatment plan, education, brief treatment, comprehensive and referral. During this process, we focus on assisting students to increase their awareness of correlation of substance use and mental health, and motivate students to begin the process of change. This program also allows counselors to provide consultation, education and support to Hamilton-Wentworth District School Board administration, student services/guidance, teachers and other Board professional staff. Group programs related to substance use may also be delivered within the classroom setting upon request. Intended outcomes for this program are that students will be more informed and better educated about substance use and how such activity may adversely affect educational progress, personal functioning and relationships. Staff will have a better understanding of student substance abuse, recognize indicators of substance misuse and be able to access appropriate. Support for students. It is also an intent that students will be able to access services that they might not have otherwise, if AY was not located in the schools. 5

6 Addiction counsellors who deliver the program are highly specialized and specifically trained to work with this specific population of students. AY counsellors assess appropriately and tailor intervention accordingly-not a one size fits all. Counsellors are formally trained in early intervention and education approached and strategies, and the principles of harm reduction.monitoringassessmenttreatment Counsellors are trained in motivational interviewing, cognitive-behavioural therapy, and the program implements best practice guidelines for concurrent disorders and youth. Counsellors provide linkages to more intensive mental health services upon assessment and throughout the course of treatment. In order to address the complexity of needs faced by youth suffering with a concurrent disorder AY counsellors provide referrals to psychiatric services, linking with primary care physicians, and provide aftercare support and follow-up for students who have required intensive inpatient treatment. Onsite school-based services create increased accessibility for youth, reduced wait-times, reduced noshows, shared treatment planning with other service providers, and increased referrals and followup. Target Audience: Secondary students ages with a diagnosed mental health disorder and are substance-involved (concurrent disorder). Clients served: per year 268 Years of operation: 20 years. Program Logic Model: Please see appendix A Literature Review There is an overwhelming prevalence of concurrent disorders within the youth population. The Centre for Addiction and Mental Health (CAMH) defines a concurrent disorder, [ ] [as] a term used to refer to co-occurring addiction and mental health problems. It covers a wide array of combinations of problems, such as anxiety disorder and an alcohol problem, schizophrenia and cannabis dependence, borderline personality disorder and heroin dependence and bipolar disorder and problem gambling ( Concurrent, 2004, p. 1). This is a growing concern for health care professionals. 14 percent of Canadian youth are affected by mental disorders that require professional intervention (Waddell, Offord, Shepherd, Hua & McEwan, 2002). As few as one in six will access specialty mental health care (Offord, Boyle, Fleming, Munroe Blum, & Rae Grant, 1989). According to the 2005 Ontario Student Drug Use Survey (OSDUS), approximately 62% of all students reported drinking within the past year ( OSDUS, 2005). In response to the growing need of addiction and mental health services for youth, there has been the establishment of school-based addiction and mental health programs. These programs, located within high schools, ensure that students can access support for their addiction and mental health concerns at an earlier time since it is more accessible to them. According to the research, early approaches to substance use education in the school setting provided information regarding alcohol, tobacco, and drugs, based on the assumption that youth 6

7 behave in a rational manner and will alter their behaviour according to the new information (Paglia & Room, 1998). Unfortunately, this strategy has been found to be ineffective (Paglia & Room, 1998). While providing drug education does increase knowledge and awareness of the adverse consequences of substance use and negative attitudes, it does not impact youth s substance use (Botvin, 1995; Tobler, 1992). In addition, providing information about the risks of substance use may be counterproductive to those who seek adventure and may in turn produce curiosity (Paglia & Room, 1998). However, although information-only approaches are not sufficient enough to impact substance use, providing information is a necessary component of any drug education program (Paglia & Room, 1998). Similarly, less importance should be placed on educating long-term adverse effects, and instead focus on the short-term effects of substance and the social drawbacks that substance use can cause (Paglia & Room, 1998). Another approach to drug education is the affective-only approach. This model assumes that those who have substance use concerns have personal problems such as low self-esteem, inadequate social skills, and poor values (Paglia & Room, 1998). Thus, the objective of this model is to enhance youth s self-image and ability to interact in a social environment (Paglia & Room, 1998). This is accomplished through discussions regarding feeling, values, and self-awareness with very little focus on substance use (Paglia & Room, 1998). Researchers of this model have found that these programs have little results and minor effects or counterproductive effects in some cases on youths substance use (Donaldson, Graham, Piccinin, & Hansen, 1995; Hawthorne, Garrard, & Dunt, 1995; Tobler, 1992). One explanation for this finding may be due to the fact that these programs do not explicitly relate skill-building to specific drug situations (Ellickson, 1995). Another approach to drug education is the psychosocial approach. The basic premise of this model is that youth engage in substance use because of social pressures from peers, family, and societal influences, as well as internal pressures (Paglia & Room, 1998). This model has a drug education component regarding health and social consequences and a component that teaches resistance skills such as decision-making skills, problem-solving, and goal setting (Paglia & Room, 1998). These programs usually take place in small-group decisions, role playing, and demonstrations (Paglia & Room, 1998). Researches have found that this model has significant behavioural effects regarding the prevention of substance use, however, the results only last a few years after initial program delivery (Tobler, 1992; Tobler & Stratton, 1997), There are limitations to this research. For instance, there is little evidence on the appropriate duration of a school-based program, other than those short-term programs is unlikely to be effective (Paglia & Room, 1998). It is unclear whether programs should focus on substance use in general or be targeted at individual substance (Paglia & Room, 1998). Although these limitations do exist, researchers have found that school-based substance use programs are effective if programs are ongoing, different approaches are used, involve students in implementation, present both the dangers and benefits of using and not using, focus on short-term effects, focus on teaching life skills, and provide a non-judgmental atmosphere (Paglia & Room, 1998). The above discussion focused on universal substance use prevention programs in a school setting. Another alternative that a school can deliver are selective prevention programs designed to target youth who are considered at risk for substance use (Paglia & Room, 1998). An example of a schoolbased program targeted for at risk youth is Project SUCCESS. Project SUCCESS (Schools Using Coordinated Community Efforts to Strengthen Students) is the placement of trained professionals in 7

8 schools to provide a range of substance use prevention and early intervention services based on evidence-based best practices ( School-Based, 2009). These counsellors are recruited to provide services to help decrease risk factors and enhance protective factors related to substance use ( School-Based, 2009). Program components include prevention education, individual and group counselling, parent programs, and referrals to appropriate agencies for youth that require more intensive counselling or treatment ( School-Based, 2009). Project SUCCESS has been tested by two evaluation studies ( School-Based, 2009). The first study was initiated in September 1995 in New York and used a pre-test and post-test comparison group of a sample of 425 students in three alternative secondary schools ( School-Based, 2009). The results indicated that after 1 year, these students demonstrated decreases in substance use and reductions in negative attitudes and behaviours ( School-Based, 2009). Specifically, there was a 37 percent decrease in substance use and 23 percent quit using substances ( School-Based, 2009). The second study used a randomized repeated measure design with a sample of 363 students attending a mainstream middle school and high school ( School-Based, 2009, p. 10). It was found that after 21 months following the intervention, Project SUCCESS participants either reduced or delayed their substance use and were less likely to have used marijuana, sniffed/huffed substances, used prescription drugs, and smoked and used substance when alone ( School-Based, 2009). In addition, research shows that Project SUCCESS is effective with both genders, students from various ethnic groups, and across grade levels from grades 9 to 12 ( School-Based, 2009). Thus, as can be seen in the success of Project SUCCESS, youth makes changes in their lives as a direct result of engaging in school-based substance use programs. Another school-based program targeted to at risk students in grades 8 to 10 is Opening Doors. This program aims to prevent and reduce substance use and other problems associated with substance use such as school dropout and violence (Paglia & Room, 1997). This program is facilitated by school staff members and health care professionals, such as social workers, from the community (Paglia & Room, 1997). The program entails the enhancement of social and personal skills, such as coping skills, via group activities and discussions (Paglia & Room, 1997). Opening Doors is a voluntary program that requires parental consent and lasts for 17 sessions (Paglia & Room, 1997). There is also a parent session that seeks to improve family interactions (Paglia & Room, 1997). Opening Doors was evaluated based on grade 9 student data from 21 schools in a quasi-experimental design (Paglia & Room, 1997). The results were promising (DeWit, Braun, et al., 1997). For instance, at a 7 month follow-up, the experimental group showed decreases in the frequency of alcohol use and binge drinking, but showed no differences in cannabis use compared to the control group (DeWit, Braun, et al., 1997). Explanations for the positive results remain unclear and could be related to the parental component or the improvement of substance use attitudes (DeWit, Braun, et al., 1997). Thus, although findings suggest mixed results, Opening Doors does show promising movements towards preventing and reducing substance use among youth within the school setting. Consequently, there is a growing need for school-based addiction and mental health programs within the youth population. Researchers have found that early approaches such as education- only approach and affective-only approach used in the school setting have been ineffective in preventing and/or reducing substance use in students. Psychosocial approaches have been more successful in preventing and/or reducing substance use in students due to the fact that this model uses components of both drug education and building life skills. There have been two programs implemented within the school-setting that are proving to be effective in preventing and/or reducing substance use in students. The first program is Project SUCCESS. Project SUCCESS recruits health care professionals from the community to provide substance use counselling within the schools. The 8

9 program was evaluated and proves to be effective in reducing substance use. The second program is Opening Doors. This program offers students 17 group sessions accompanied by a parent session to teach drug awareness and to build on life skills. The program produced mixed results in that alcohol use declined, but cannabis and cigarette use were not impacted. This research shows that schoolbased addiction and mental health programs are being implemented and are showing to be successful through trial and error. Consequently, school-based addiction and mental health programs are continually being evaluated and refined to ensure that youth are receiving services based on evidence-informed best practices. C. Methodology Extensive Quantitative Data was collected and stored in the agencies data-base through the Provincial Ministry of Health s funded data base (Catalyst) for children and youth ages This quantitative data is gathered and collated and reflects our individual agency s work as well as data gathered province-wide. Captured in this data are: client demographics (age, gender etc.),ethnicity, referring source, legal status, mandated treatment, relationship status, self-identified problem substances (quantity, frequency and type),iv drug use, mental health screen including risk of self harm, suicidal ideation, depression, past suicide attempts, past hospitalizations, history of mental health diagnosis and treatment (including past or current medications). Extensive Qualitative Data was collected in the comprehensive client record which monitors the process of change over time in several life domains in addition to substance use and mental health, according to the treatment goals established by youth at the outset and throughout treatment. Staff report reviewed with client upon completion of assessment and upon completion of treatment when possible. A client satisfaction survey was distributed at least three months after initiation of treatment and measures average length of stay in treatment, client s perception of being listened to and understood, increased trust in the goal, efficacy in individual goal setting, confidence in goal achievement. Youth self report. D. Pilot Results: Agency data identifies the five most common mental health disorders reported by students at intake are: Attention-Deficit/Hyperactivity Disorder, Conduct, Disorder, Depression and Bipolar Disorder, Social Anxiety Disorder, and Post-Traumatic Stress Disorder. Agency data identifies the most common substances reported by students are alcohol, marijuana, and opioids. In addition, students report using: Benzodiazepines Sedatives Solvents Cocaine Hallucinogens Anabolic Steroids Sedatives GHB Stimulants-amphetamine (speed) Hallucinogenic stimulants MDMA (ecstasy) Dissociative anaesthetics (ketamine, PCP) 9

10 As reflected in the client record, students report substance use across the continuum of need including: experimental substance use, regular substance use, problematic substance use, dependant substance use, and harmful substance use. Implementation and Results of Client Satisfaction Survey In the month of June client satisfaction surveys were distributed to students who had attended at least 3 appointments to complete the client satisfaction survey entitled, How Are We Doing? See Appendix B. The questionnaire design included 7 scored questions, 5 of which were based on factors identified as affecting positive outcomes in the counselling process. Each scored question was followed by space for comments. The questionnaire was kept brief and relatively basic in order to increase ease and of completion. 39 clients completed the survey, providing a small student sampling. The surveys were coded in order that data could be separated by counsellor. Each counsellor receives the results specific to his or her client group and information gathered is part of the organizations overall quality improvement plan. Preliminary Findings Of the responding clients 43.5% had been coming to AY for more than 6 months, 23.2% for less than 6 months, 20.3% less than 3 months and 13% less than 1 month. The survey reflects 19.1% of clients who were self-initiating, 47% who came in response to a suggestion from someone else, 26.5% coming in response to a strong recommendation of someone else and 7.4% coming because they had to The questions were rated in the following manner: 1 Yes definitely 2 Yes, generally 3 No, not really 4 Definitely not In response to the question, Do you feel listened to? all clients answered either yes, definitely which was represented by a score of 1 or yes, generally which was represented by a score of 2. The average score was 1.1 (1.08). In response to the question Are you getting the kind of service you want? the average score was 1.2 (1.23). All scores but one was 1 & 2 In response to the question Do you feel that you can talk to your counsellor? the average score was 1.2 (l.2). In response to the question With your counsellor, have you developed your own realistic goals to help you make the changes to your life that you want? the average score was 1.6 (1.5) with a range of 1 to 3. 10

11 In response to the question How confident are you that you can move forward in achieving some of your goals? the average score was 1.5 (1.5 There continues to be a high level of client satisfaction with AY services. In response to the question What do you think we should keep doing? The following themes included the importance of goal setting, easy access to addiction and mental health education, assessment, treatment on site in secondary schools, and ability of specialized counsellors to establish therapeutic rapport with students. Summary and Recommendations of Preliminary Findings: Implementing the questionnaire in a time limited period once a year provided an adequate snapshot of the feedback of current clients. It is recommended that this process be continued. It is recommended that counsellors continue to provide the high quality of service reflected in the feedback. E. Stakeholder involvement and Knowledge Exchange Knowledge Exchange Plan (Ongoing): Over the implementation of the program evaluation in partnership with the Centre of Excellence, AY continued to partner with the CCSA-Canadian Centre on Substance Abuse AY continued to work with CCSA KE specialists who are available to mentor Alternatives for Youth with KE initiatives to support Systems Improvement on an ongoing basis. AY will continue to work with CCSA on the uptake of CCSA s Prevention Standards by proving consultation to CCSA on the correlation befween prevention and health promotion as part of the continuum of treatment. Most recently the Centre of Excellence has embarked on a Knowledge Exchange Strategy to assist system improvement activities at the local level and AY as participated in some of those initial activities including an education session on Implementation Science. As AY is a MCYS funded agency, AY will continue to be an active participant in the provincial Moving on Mental Health Strategy as it begins to be implemented in our Hamilton region. AY has also been an active participant in the Provincial System Improvement Service Collaborative lead under the provincial leadership of the Centre of Addiction and Mental Health. The purpose of the initiative is to support system improvement by utilizing the principles of implementation science in evidence informed decision-making with the ultimate goal of supporting evidenced informed practice that can be sustained and evaluation at the agency, community, and provincial level. The initiative is currently in the implementation phase. KE Objectives Achieved: Raise Awareness of prevalence of concurrent disorders within the student population: AY was successful in its submission of an abstract for a presentation at CCSA S National Issues of Substance Use Conference held in Ottawa in November The early findings of our evaluation were met with positive evaluations and an invitation to feature our early findings on the Centre for Addiction 11

12 and Mental Health s Knowledge Exchange Network (EENET), providing an on-line learning opportunity with a broad reach. Increase Knowledge of effectiveness of evidence informed interventions for students with concurrent disorders across sectors (Children and Youth Mental Health, Mental Health and Addiction, Education). As has already been mentioned AY is currently collaborating with two provincial research initiatives that will provide extensive program evaluation as well as the implementation of new screening and assessment tools. Strengthen cross-sector relationships for the purpose of improved treatment options for students with concurrent disorders. In the spring of 2014 AY will be integrating its addiction and mental health program for transitional age youth as part of a broader Youth Wellness Centre Initiative and will be participating in a rigorous program evaluation of a promising practice. F. Conclusions, recommendations and next steps: Further comprehensive evaluation opportunities have been explored in collaboration with other researchers. To that end, Alternatives for Youth has applied to Health Canada s Drug Treatment Funding Program along with several other youth serving agencies for a two year evaluation and research grant for the purpose of developing a provincial evaluation framework under the leadership of Pine River Institute, and with the support of the Ministry of Health and Long Term Care. Further, Alternatives for Youth, as part of the provincial mental health and addiction strategy, will be implementing the GAIN suite of tools to provide further comprehensive screening, assessment, treatment and follow-up as part of a broader system improvement initiative)pending approval from Health Canada. The initial support of the Centre of Excellence Planning for Evaluation Grant allowed the agency to confirm the importance of program evaluation, gain new knowledge and skill specific to program evaluation, and pursues additional opportunities for further program evaluation. As a result, a more robust program evaluation framework will be developed in collaboration with our provincial and national research partners. It has been determined that given the limitations of our current organizational infrastructure, current staff compliment, and lack of resources specific to evaluation and research that Alternatives for Youth will be in a better position to conduct program evaluation and research activities through further collaboration. Our experience with the Centre of Excellence has been extremely helpful in confirming the need for this important work to continue on a broader scale. 12

13 G.References Botvin, G. J. (1995). Principles of prevention. In R. H. Coombs & D. Ziedonis (Eds.), Handbook on drug abuse prevention: A comprehensive strategy to prevent the abuse of alcohol and other drugs (pp ). Boston: Allyn and Bacon. Concurrent Substance Use and Mental Health Disorders: An Information Guide. (2004). Centre for Mental Health and Addiction. Retrieved from formation/concurrent_disorders/pages/concurrent-disorders.aspx DeWit, D. J., Braun, K., Steep, B., Ellis, K., Rye, B. J., Silverman, G., Smythe, C., & Stevens- Lavigne, A. (1997). Evaluation of an in-school drug prevention program for at-risk youth. Manuscript submitted for publication. Donaldson, S. I., Graham, J. W., Piccinin, A. M., & Hansen, W. B. (1995). Resistance-skills training and onset of alcohol use: Evidence for beneficial and potentially harmful effects in public schools and in private Catholic schools. Health Psychology, 14, Ellickson, P. L. (1995). Schools. In R. H. Coombs & D. Ziedonis (Eds.), Handbook on drug abuse prevention: A comprehensive strategy to prevent the abuse of alcohol and other drugs (pp ). Boston: Allyn and Bacon. Hawthorne, G., Garrard, J., & Dunt, D. (1995). Does Life Education s drug education programme have a public health benefit? Addiction, 90, Ontario Student Drug Use Survey (OSDUS): Highlights. (2005). Centre for Addiction and Mental Health. Retrieved from _and_backgrounders/archives/2005/pages/osdus2005_highlights.aspx Paglia, A. & Room, R. (1997). Preventing Substance Use Program Among Youth: A Literature Review & Recommendations. Centre for Addiction and Mental Health. Retrieved from School-Based Drug Abuse Prevention: Promising and Successful Programs. (2009). National Crime Prevention Centre. Retrieved from drg-abs-eng.pdf Tobler, N. S. (1992). Drug prevention programs can work: Research findings. Journal of Addictive Diseases, 11, 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,

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