Drug Abuse Prevention Curricula in Schools

Transcription

1 Botvin, G. J., & Griffin, K. W. (2003). Drug abuse prevention curricula in schools. In Z. Sloboda & W. J. Bukoski (Eds.), Handbook of Drug Abuse Prevention: Theory, Science, and Practice (pp ). New York: Kluwer Academic/Plenum Publishers. CHAPTER 3 Drug Abuse Prevention Curricula in Schools Gilbert J. Botvin Kenneth W. Griffin INTRODUCTION Schools are the focus of most attempts to develop effective approaches to drug abuse prevention. In addition to their traditional educational mission, schools often assume responsibility for addressing a variety of social and health problems, such as health education that targets tobacco, alcohol, and drug abuse, as well as teenage pregnancy and aids. Although there is some debate about whether schools should provide such programming, particularly with renewed concerns about academic standards, schools offer the most efficient access to large numbers of children and adolescents. Moreover, many educators now recognize that certain problems, such as drug abuse, are a significant barrier to the achievement of educational objectives. The U.S. Department of Education, for example, has included drug-free schools as one of its goals for improving the quality of education. The first school-based approaches to drug abuse prevention were based on intuitive notions of how to prevent drug abuse. They included information dissemination, affective education, and alternatives programming. More recent approaches to prevention are grounded in psychological theories of human behavior and include social resistance skills training and competenceenhancement approaches. This chapter will first describe the traditional prevention approaches and then the newer psychosocial approaches. Finally, it will look at important issues regarding the development, implementation, evaluation, and dissemination of school-based drug abuse Gilbert J. Botvin and Kenneth W. Griffin Institute for Prevention Research, New York Hospital-Cornell Medical Center, New York, New York

2 Drug Abuse Prevention Curricula in Schools 46 Table 3.1. Overview of Major Prevention Approaches Approach Focus Methods Information dissemination Affective education Alternatives Social resistance skills Competence enhancement Increase knowledge of drugs, their and consequences of use; promote anti-drug use attitudes Increase self-esteem, responsible decision making, interpersonal growth; generally includes little or no information about drugs Increase self-esteem, self-reliance; provide viable alternatives to drug use; reduce boredom and sense of alienation Increase awareness of social influence to smoke, drink, or use drugs; develop skills for resisting substance use influences; increase knowledge of immediate negative consequences; establish non-substance-use norms Increase decision making, personal behavior change, anxiety reduction, communication, social and assertive skills; application of generic skills to resist substance use influences Didactic instruction, discussion, audio/video presentations, displays of substances, posters, pamphlets, school assembly programs Didactic instruction, discussion, experiential activities, group problem-solving exercises Organization of youth centers, recreational activities; participation in community service projects; vocational training Class discussion; resistance skills training; behavioral rehearsal; extended practice via behavioral homework ; use of same-age or older peer leaders Class discussion; cognitive behavioral skills training (instruction, demonstration, practice, feedback, reinforcement) prevention programs. Table 3.1 summarizes the focus and methods of each major type of prevention approach. Tables 3.2 through 3.5 review research evidence on the effectiveness of each approach. TRADITIONAL PREVENTION APPROACHES Information Dissemination and Fear Arousal Providing students with factual information about drugs and drug abuse is the most common approach to prevention. Typically, students are taught about the dangers of tobacco, alcohol, or drug use in terms of the adverse health, social, and legal consequences. Information programs also define various patterns of drug use, the pharmacology of drugs, and the process of becoming a drug abuser. Many of these programs describe the pros and cons of drug use or have students participate in debates in order to lead them to conclude that they should not use drugs. Some programs have police officers come into the classroom and discuss law enforcement issues, including drugrelated crime and penalties for buying or possessing illegal drugs. Others use doctors or other health professionals to talk about the adverse health effects of using drugs or invite former drug addicts into the classroom to discuss the problems they encountered as the result of drug abuse. More recently, there has been an emphasis on using same-age or older peers to discuss drug abuse.

3 47 Gilbert J. Botvin and Kenneth W. Griffin Table 3.2. Selected Studies Testing Informational Approaches a Intervention Evaluation Investigator(s) Participants approach design Results Degnan (1972) 9th-grade 10 weeks, information Pre post No significant students based attitude changes O Rourke & High school 6-month course Post-test Significant attitude Barr (1974) students using NY state only changes for males curriculum guide only Rosenblitt & 7th-grade Six 45-min sessions; Pre post; Increased knowledge; Nagey (1973) students information based no control trend toward increased presented as reasons group usage of alcohol and for use and nonuse tobacco a Adapted from Kinder, Pape, & Walfish (1980). Programs that rely exclusively on providing students with facts about drugs and drug abuse are based conceptually on a cognitive model of drug use and abuse. This model assumes that people make a more or less rational decision to either use or not use drugs and that those who use drugs do so because they are unaware of the adverse consequences of drug abuse. From this perspective, the solution to the problem of drug abuse is to educate students about the negative consequences of drug abuse and increase their knowledge about drugs and drug abuse. Frequently, in an effort to present information in a fair and balanced way, both positive and negative information about drug use is provided. The danger in this, of course, is that the reasons for not using drugs may not necessarily be seen by all students as outweighing the reasons for using drugs. In fact, some studies suggest that informational approaches may lead to increased drug use because they can stimulate curiosity (Stuart, 1974; Swisher et al., 1971). Table 3.2 summarizes a representative sample of studies evaluating traditional information dissemination approaches. In an effort to dramatize the dangers of using drugs, some programs also use fear-arousal techniques designed to scare individuals into not using drugs. The underlying assumption is that evoking fear is more effective than a simple exposition of facts. These approaches go beyond a balanced and dispassionate presentation of information and provide a clear and unambiguous message that using drugs is dangerous. Finally, some informational approaches are combined with moral appeals to not use drugs because of the fundamentally debased nature of drug abuse. In these programs providers not only offer factual information about drugs but also preach to students about the evils of smoking, drinking, or using drugs, and exhort them to avoid such behaviors on religious or moral grounds. Effectiveness. One problem that has plagued the field of prevention is that, until recently, there were few high-quality evaluation studies. In fact, most of the published reports on drug abuse prevention programs in the 1970s and early 1980s either did not have evaluation components or used evaluation methodologies that were seriously flawed (Schaps et al., 1981). Most of the evaluation studies that were conducted focused on knowledge and attitudes instead of on actual drug use. Evaluation studies of informational approaches to prevention tended to show some impact on knowledge and anti-drug attitudes but consistently failed to show any impact on tobacco, alcohol, or drug use or intentions to use drugs. Several meta-analytic studies confirmed this overall lack of behavioral effects. In a meta-analysis of 143 adolescent drug education programs, Tobler (1986) reported that information-based programs had an impact on drug knowledge but had no effect on other outcome measures, including drug use. In a separate meta-analysis

4 Drug Abuse Prevention Curricula in Schools 48 of 33 school-based drug education programs, Bangert-Drowns (1988) found positive effects on knowledge and attitudes but no effects on drug use. Consequently, the existing literature calls into question the basic assumption of the information dissemination model that increased knowledge will result in attitude and behavior change. In summary, while it is likely that an awareness of the hazards of using drugs does play some role in deterring drug use, it is increasingly clear that the causes of drug abuse are complex and that prevention strategies that rely either solely or primarily on information dissemination are simply not effective. Affective Education Another common approach to drug abuse prevention is known as affective education. Rather than focusing on cognitive factors, affective education approaches assume that promoting personal affective development in students will directly reduce the likelihood of drug abuse. Affective education approaches often include content on decision making, effective communication, and assertiveness, and many include content on norm-setting messages. For example, the affective approaches sometimes include material showing that most people who smoke or use alcohol do so in a responsible manner. Effectiveness. Like informational approaches, affective education has produced disappointing results. Although affective education approaches can have an impact on one or more of the correlates of drug use, they have not demonstrated an impact on drug use (Kearney & Hines, 1980; Kim, 1988). Rather than focusing on skills training, these programs typically emphasized experiential games and classroom activities designed to target personal growth, self-understanding, and self-acceptance. However, there is no evidence that these exercises actually improved decision making, assertiveness, or communication skills. Furthermore, it now seems likely that responsible-use messages may have been counterproductive by conveying the message that drug use is acceptable as long as it is done in a responsible fashion. Other limitations of the affective education approach are the failure to link program content to drug-specific situations and failure to acknowledge the role of social influences and peer pressure in adolescent experimentation with drugs. In summary, while more comprehensive than information dissemination approaches, the affective education approach to drug abuse prevention has several major weaknesses, including a narrow and incomplete focus on the causes of drug abuse and the use of ineffective methods to achieve program goals. Table 3.3 summarizes a representative sample of studies that evaluated affective education approaches. Alternatives Programming The idea behind alternatives programming is to provide adolescents with activities that can serve as alternatives to drug use. The original model for this prevention approach included the establishment of youth centers that provided a set of activities, such as sports, hobbies, community service, or academic tutoring. It was assumed that if adolescents were provided with real-life experiences that were as appealing as drug use, these activities would take the place of involvement with drugs. Outward Bound and similar programs represent a second type of alternatives approach. They were developed in the hope that they would alter the affective cognitive state of participants and improve the way they feel about themselves, others, and the world. These programs provide typically healthy, outdoor activities designed to promote teamwork, self-confidence, and

5 Table 3.3. Selected Studies Testing Affective and Alternative Approaches Investigator(s) Participants Intervention approach Evaluation design Results Moskowitz et al. 3rd 4th-graders 42 sessions over 2 years; Magic Circle (1982) technique designed to increase opportunities to communicate in small groups; implemented by teachers Schaps et al. 4th 6th-graders Effective Classroom Management (ecm) (1984) focuses on general teaching style; incorporation of communication and nonpunitive discipline skills with self-esteem enhancement by teacher; implemented by teachers Malvin et al. 7th 8th-graders 12-session training by teachers of peer (1985) tutors (cross-age peer tutoring); tutors help younger children 4 times per week for a semester Malvin et al. 7th 8th-graders 1 period per day for a semester; students (1985) work in a school store 2 3 times per week Schaps et al. 7th 8th-graders 12 sessions; decision making, goal (1982) setting, assertiveness, advertising, social influences, knowledge of drugs; implemented by teachers (1 year) (1 and 2 years) (1 and 2 years) Pretest; follow-up (1 and 2 years) (1 year) No difference between those in Magic Circle and controls on variables relating to drug use and variables measuring drug use No pattern of effects for ecm was observed for either elementary or junior high school students Students liked tutoring but disliked weekly meetings; no effects on outcome variables such as self-esteem and school liking Students liked daily class sessions and working in store; no effects on outcome variables such as self-esteem and school liking Effects only on 7th-grade girls drug knowledge, perception of poor attitudes; but results disappeared at follow-up; no effects for 8th grade girls or boys

6 Drug Abuse Prevention Curricula in Schools 50 self-esteem. A third alternatives approach was designed to meet the kind of needs or expectancies that are often said to underlie drug use. For example, the need for relaxation or more energy might be satisfied by exercise programs, sports, or hiking; the desire for sensory stimulation might be satisfied by activities that enhance sensory awareness (such as learning to appreciate the sensory aspects of music, art, and nature); or the need for peer acceptance might be satisfied through participation in sensitivity training or encounter groups. None of the evaluations of alternatives approaches have found any impact on drug use (Schaps et al., 1981, 1986). Table 3.3 summarizes a representative sample of studies evaluating alternatives approaches to drug abuse prevention. SOCIAL-INFLUENCE APPROACHES Toward the end of the 1970s, a major shift in drug abuse prevention research began. This shift occurred partly out of both a growing disappointment with traditional prevention approaches and a recognition of the importance of psychosocial factors in promoting the initiation of drug use. Unlike previous prevention approaches, the intervention strategies that were the focus of prevention research during the 1980s and 1990s had a stronger grounding in psychological theories of human behavior. Richard Evans and his colleagues at the University of Houston are credited with launching this line of prevention research (Evans, 1976; Evans et al., 1978). Evans s work emphasized the importance of social and psychological factors in promoting the onset of cigarette smoking and used a prevention approach based on McGuire s persuasive communications theory (McGuire, 1964, 1968). From this perspective, adolescent cigarette smoking is the result of social influences from peers and the media to smoke cigarettes, persuasive advertising appeals, or exposure to smokers who serve as role models for students. Psychological Inoculation A major component of Evans s prevention approach was based on a concept in McGuire s work called psychological inoculation. As applied by Evans to cigarette smoking, adolescent nonsmokers were inoculated against the kind of pro-smoking messages they would be likely to encounter in real-life situations. This was accomplished by exposing students to pro-smoking messages first in a relatively weak form and then in progressively stronger forms. In addition to preparing adolescents for pro-smoking influences, this prevention approach attempted to teach them how to deal with such influences. For example, a common situation for adolescents is that they are offered a cigarette by a peer and called chicken if they refuse to smoke. Students are taught to handle this type of situation by having responses ready, such as, If I smoke to prove to you that I m not chicken, all I m showing is that I m afraid of not doing what you want me to do. I don t want to smoke, I m not going to. Or, since adolescents are likely to see peers posturing and acting tough by smoking, they can be taught to think to themselves: If they were really tough, they wouldn t have to smoke to prove it. Correcting Normative Expectations The prevention approach developed by Evans included periodic surveys of smoking among students along with collection of saliva samples as objective confirmation of smoking behavior. After each survey, actual smoking prevalence rates in each classroom were announced to students. Since

7 51 Gilbert J. Botvin and Kenneth W. Griffin adolescents have a general tendency to overestimate the prevalence of tobacco, alcohol, and drug use (Fishbein, 1977), many students learned that actual classroom smoking rates were lower than they had expected. This assessment and feedback procedure helped correct the common misperception that cigarette smoking is a highly normative behavior engaged in by most adolescents. A seminal research paper by Evans and colleagues (1978) demonstrated the importance of correcting such expectations. In this study, classrooms were randomized to one of three conditions: (1) students receiving assessment and feedback concerning classroom smoking rates, (2) students receiving assessment and feedback plus the inoculation intervention, and (3) a control group. The results of this study showed that students in the two prevention conditions had smoking onset rates that were about half those observed in the control group. This was the first research to show that prevention could work that individuals receiving a prevention program would have significantly lower rates of use than would those not receiving the program. An interesting aspect of this study is that the inoculation intervention did not produce any incremental reduction in smoking onset over that produced by the assessment/feedback procedures. In fact, in retrospect it is evident that the prevention effect generally attributed to the inoculation component of the intervention was actually the result of providing students with feedback concerning the actual levels of smoking in their classroom. That is, an important active ingredient in the prevention approach developed by Evans and his colleagues was the process of correcting expectations that nearly everybody smokes cigarettes. Although the importance of correcting such expectations was originally overlooked, the success of the Evans smoking prevention study led to a dramatic increase in prevention research that transformed the entire prevention field. This research initially targeted cigarette smoking but later began to address the use of alcohol and other drugs. Social Resistance Skills Training Over the years several variations on the prevention strategy described previously have been developed and tested. In general, these approaches placed little emphasis on the psychological inoculation procedures developed by Evans and focused extensively on teaching students how to recognize and deal with social influences from peers and the media to use drugs. An assumption is that many adolescents do not want to smoke, drink, or use drugs but lack the confidence or skills to refuse offers to engage in these behaviors. Based on this, one of the most important aspects of the approach is an increased emphasis on skills training to help students resist social influences. This approach is called social influence (because it targets social influences that promote drug use), refusal skills (because they teach students how to refuse drugs), and social resistance skills (or simply resistance skills, because they teach students skills for resisting social influences to use drugs). These terms are used interchangeably in the literature, and any one of them is an appropriate descriptor for this class of prevention approaches. The term resistance skills is used in this chapter because it captures two central and distinctive aspects of these prevention approaches: (1) the focus on increasing student resistance to negative social influences to engage in drug use and (2) the focus on skills training. As a class of preventive interventions, these approaches are similar in that they are based on social-learning theory (Bandura, 1977) and on a conceptual model that stresses the fundamental importance of social factors in promoting the initiation of adolescent drug use. Although this model includes social influences coming from the family, peers, and the media, the focus of most preventive interventions is on the last two, with the primary emphasis on peer influences.

8 Drug Abuse Prevention Curricula in Schools 52 Methods. A major emphasis in resistance skills training approaches is on teaching students how to recognize situations in which they are likely to experience peer pressure to smoke, drink, or use drugs. The goal is to teach students ways to avoid these high-risk situations and give them the knowledge, confidence, and skills needed to handle peer pressure in such situations. These programs also frequently include a component that is intended to make students aware of prosmoking influences from the media, with an emphasis on the techniques used by advertisers to influence consumer behavior. Students are taught to recognize advertising appeals designed to sell tobacco products or alcoholic beverages as well as how to formulate counterarguments to those appeals. Other methods commonly used in resistance skills training include having students make a public commitment not to smoke, drink, or use drugs. However, one study (Hurd et al., 1980) suggests that this component may not contribute to any real prevention effects. Finally, following the original model developed by Evans, prevention approaches began to include a component to correct normative expectations that the majority of adolescents smoke, drink, or use drugs.this has been accomplished in various ways. In addition to the classroom survey and feedback procedure developed by Evans, students may be asked to conduct their own surveys and provide the results to the class. Alternatively, students may be asked to estimate how many teenagers and how many adults smoke, drink, or use drugs, and then are provided with the correct statistical information from national or regional survey data. Recently, it has been proposed that resistance skills training may be ineffective in the absence of conservative social norms against drug use since, if the norm is to use drugs, adolescents will be less likely to resist offers of drugs (Donaldson, et al., 1996). This suggests that correcting normative expectations and attempting to create or reinforce conservative beliefs about the prevalence and acceptability of drug use is of central importance to the success of resistance skills training programs. Effectiveness. A growing number of studies have documented the effectiveness of prevention approaches that use resistance skills training (Arkin et al., 1981; Donaldson et al., 1994; Hurd et al., 1980; Luepker et al., 1983; Perry et al., 1983; Snow et al., 1992; Sussman et al., 1993; Telch et al., 1982). The focus of the majority of these studies has been on smoking prevention, with studies typically examining rates of smoking onset, overall smoking prevalence, or scores on an index of smoking involvement. For the most part, studies indicate that the resistance skills prevention approach is capable of reducing smoking by 30 to 50% after the initial intervention, based on a comparison of the proportion of smokers in the experimental group to the proportion of smokers in the control group (Arkin et al., 1981; Donaldson et al., 1994; Sussman et al., 1993); Studies reporting results in terms of smoking incidence have shown reductions ranging from approximately 30 to 40%, when comparing the proportion of new smokers in the experimental group to the proportion of new smokers in the control group. Several studies have demonstrated reductions in the overall prevalence of cigarette smoking in terms of both occasional smoking (one or more cigarettes per month) and regular smoking (one or more cigarettes per week). Although there are fewer studies of the impact of resistance skills training approaches on alcohol or marijuana use than on tobacco use, the magnitude of the reductions that have been reported in many cases is similar to that found for tobacco use (e.g., McAlister et al., 1980; Shope et al., 1992). However, one meta-analysis of resistance skills programs found fewer behavioral effects for alcohol interventions relative to smoking interventions (Rundall and Bruvold, 1988). Nevertheless, resistance skills programs as a whole have generally been successful. A comprehensive review of resistance skills tudies published from 1980 to 1990 reported that the majority of prevention studies (63%) had positive effects on drug use behavior, with fewer studies

9 Table 3.4. Selected Studies Testing Social and Resistance-Skills Approaches Investigator(s) Participants Intervention approach Evaluation design Results Evans et al. (1978) 7th-graders 4-session social pressures curriculum using videotapes, small-group discussion, and feedback on smoking rates; peers used in videotapes McAlister, Perry, & Maccoby (1979) 7th-graders 7-session social pressures curriculum using discussion and role playing; slightly older peers implemented curriculum Perry et al. (1983) 10th-graders 3-session social pressures curriculum; implementation by regular classroom teachers versus college students Hurd et al. (1980), Minnesota Team 7th-graders 5-session social pressures curriculum; conducted by college students; utilized videotapes, discussion, and role playing; compared personalized videotapes where role models were known to students with nonpersonalized videotapes Pre post Smoking onset rates for initial nonsmokers exposed to the social pressures curriculum did not differ from onset rates for subjects exposed to repeated testing and a film on physiological effects of smoking (2 years) Intervention group reported substantially less smoking following treatment and 1 and 2 years thereafter; substantially lower rates of alcohol and marijuana use were also found 1 year following treatment Pre post Intervention was no more effective than (2 years) two comparison treatments in reducing smoking; no significant differences were found between the two types of instructors Immediately following treatments, the personalized and nonpersonalized groups reported significantly lower smoking rates than the no-treatment control groups, with no significant difference between the two experimental groups; two years following treatment, smoking rates for the personalized group were significantly less than the nonpersonalized and control groups, and smoking rates for the latter two groups did not differ 53

10 Arkin et al. (1981), Minnesota Team Murray et al. (1984), Minnesota Team 7th-graders 4 intervention conditions included (1) social pressures curriculum led by professional health educator with media supplement, (2) friendly pressures led by same-age peers with media supplement, (3) social pressures led by peers without media, and (4) long-term health consequences 7th-graders Same as above except regular classroom teachers replaced professional health educators Best et al. (1984) 6th-graders 8-session social influence approach, plus decision making; 2 boosters in 7th grade; 1 booster session in 8th grade; health educators Pentz et al. (1989); Midwestern Prevention Project 6th- and 7th-graders 10-session intervention program includes school, parent, mass-media components; school-based intervention includes resistance training, normative education, and health education; reinforced by role-play, problem solving, discussion and practice; taught by classroom teachers, using peer leaders; includes booster sessions (1-year) (1 year) (2-1/2 years) (2 years) Among initial nonsmokers, the long-term consequences curriculum had the most favorable initial results, but 1 year later the peer-led social pressures conditions had lower smoking rates; no differences were found for initial smokers Among initial nonsmokers, no differences were found among the 4 treatment conditions following treatment; smoking rates for all groups combined were lower than a comparison group receiving standard health curriculum; differences among groups for initial smokers were not significant, although there was a tendency toward higher smoking levels for the teacher-led social pressures curriculum Significant effects on cross-sectional prevalence; significant reductions in experimental smokers; significant impact on high-risk students for experimental to regular smoking Proportion of smokers lower in intervention group for recent smoking and having smoked within 1 month; intervention group marginally lower in number of students who had ever smoked (cont.) 54

11 Table 3.4. (Continued) Investigator(s) Participants Intervention approach Evaluation design Results Johnson et al. (1990); Midwestern Prevention Project MacKinnon et al. (1991); Midwestern Prevention Project Rohrbach et al. (1994); Midwestern Prevention Project Donaldson et al. (1994, 1995); Adolescent Alcohol Prevention Trial Shope et al. (1992); Alcohol Misuse Prevention Study Ellickson & Bell (1990); Project alert 6th- and 7th-graders; high and low risk 6th- and 7th-graders 10-session school-based social influences curriculum mentioned above 10-session school-based social influences curriculum mentioned above 6th-graders 13-session social influence school prevention curriculum similar to Pentz et al. (above), plus parent curriculum consisting of parent child homework, parent training workshops, and community activities. 5th-graders 9-session school-based program assessing 5th- and 6th-graders 7th-graders; urban, suburban, and rural the effectiveness of Resistance-Skills Training, Normative Education, and drug education; 7th-grade booster sessions; includes discussion, homework, and video 4-session resistance training curriculum, with three booster sessions; involves health education, coping strategies; uses positive reinforcement, roleplay, homework, and video 8-session social influence and resistance skills training curriculum; three 8th-grade booster sessions; utilized role-play and discussion; conducted by classroom teachers, and older teenagers (3 years) (1 year) (18 month) (3-years); tested information only, resistance training, normative education and combined curricula (26 months); compared intervention, intervention plus boosters, and control (3-, 12-, and 15-month); program tested on students in three levels of risk Reductions in tobacco and marijuana use; equivalent reductions across risk levels; with marginal effect for lifetime smoking Reductions in cigarette smoking, drinking, and marijuana use; positive effects on mediating variables, such as communication skills, and beliefs about friends tolerance of drug use 73% of parents participated in at least one of the components; parent participation in program resulted in less cigarette use, and marginally associated with less alcohol use at follow-up. Resistance training and normative education significantly increased the skills they targeted; only normative education positively effected substance use into 8th grade; resistance training-only condition increased levels of substance abuse No treatment effect as a whole for alcohol use, or misuse; program effects found for alcohol misuse in the subgroups who had experienced drinking prior to implementation Initial reductions in drinking for different risk levels; intervention effects for marijuana and cigarette initiation for all risk levels; reductions in drinking not sustained after 7th grade 55

12 Bell et al. (1993); Project alert 7th-graders Same as above (2 years) Ellickson et al. (1993); Project alert Flynn et al. (1992) 4th-, 5th-, and 6th-graders Perry et al. (1992), Minnesota Team Graham et al. (1990); Project smart 7th-graders Same as above (6 years) 4-year mass media and school-based educational intervention; 4 sessions/year in grades 5 8, and 3 sessions/year in grades 9 and 10; includes decision making, resistance training, and health information; mass-media program included health information and resistance skills components 7th grade 5-year behavioral health and community education program; school-based component focuses on health education, resistance skills, normative beliefs, and peer and media influences; includes role-play, discussion, and a public commitment to abstain; community smoking prevention in 7th grade 7th-graders 12-session social skills and drug resistance curriculum, and a 12-session affective education curriculum; utilized role-play and discussion; conducted by health educators, with peer assistants (4 years annually); compared school-only and media-plus-school interventions (7-year, annually) Pre post; comparison of 2 program types within 6 subgroups (males, females, Asians, Blacks, Hispanics, and Whites); 1-year follow-up of 3 cohorts Effects on cognitive risk factors persist through 9th grade in teen-led condition; all effects on actual use decay after 2 years Effects on substance use decay after intervention; some effects on cognitive risk factors persist until 10th grade Reductions in smoking and targeted mediating variables for media-plus-school condition Significant reductions in smoking prevalence and intensity at all subsequent test points through high school Positive effects for females in both programs for cigarette smoking and alcohol consumption, significant sex by program interactions for cigarettes and marijuana use 56

13 Table 3.5. Selected Studies Testing Competence Enhancement Approaches Investigator(s) Subjects Intervention approach Evaluation design Results Schinke & Gilchrist (1983) Gilchrist & Schinke (1983) Botvin & Eng (1980); Botvin et al. (1980); Life Skills Training Botvin & Eng (1982); Life Skills Training Botvin, Renick, & Baker (1983); Life Skills Training Botvin, Baker, Renick et al. (1984); Life Skills Training Botvin, Baker, Botvin et al. (1984); Life Skills Training 6th-graders 8-session social skills curriculum focusing on problem solving, decision making, and social pressures resistance 6th-graders 8-session social skills training (15 months) 8th 10th graders 10-session life skills training focusing on communication, decision making, assertion, and social pressures resistance; adult educational specialists as implementers 7th-graders 12-session life skills training using slightly older peer leaders 7th-graders 15-session life skills training using regular classroom teachers; comparisons were made between intensive (daily session) and prolonged (weekly sessions) format 7th-graders 20-session life skills training; implementation by older peers versus classroom teachers 7th-graders 20-session life skills training targeting alcohol misuse using classroom teachers Pre post Substantially lower smoking rates 6 months following treatment for experimental vs. no-treatment control group (3 months) (1 year) (1 year) Substantially lower smoking rates 3 and 15 months following treatment for experimental group versus a comparison discussion group and a no-treatment control group Substantially lower onset rates among initial nonsmokers immediately after and 3 months following treatment compared with no-treatment control group Lower smoking rates among initial nonsmokers immediately after and 1 year following treatment Among initial nonsmokers, both experimental groups had lower smoking rates immediately after and 1 year following treatment. No differences were found between the two scheduling formats immediately following treatment, but smoking rates were lower for the intensive format 1 year later. Among initial smokers, no differences were found Pre post Substantially lower substance use rates (6 months) immediately following treatment for the peer-led group compared with the teacher-led group and no-treatment control group. Rates for the teacher-led group did not differ from the control group Significantly lower rates of alcohol use, misuse, and drunkenness at 6 months follow-up compared to no-treatment control group 57

14 Botvin, Dusenbury et al. (1989); Life Skills Training Botvin, Batson et al. (1989); Life Skills Training Botvin, Baker, Dusenbury et al. (1990); Life Skills Training Botvin, Baker, Filazzola et al. (1990); Life Skills Training Botvin et al. (1992); Life Skills Training Caplan et al. (1992); Positive Youth Development Program 7th-graders (urban, Hispanic) 15-session life skills training using classroom teachers 7th-graders (urban, Black) 12-session life skills training using classroom teachers 7th-graders 15-session life skills training using classroom teachers; 10 boosters in 8th grade, 5 boosters in 9th grade; Sessions include decision making, assertiveness, self-esteem, stress management, media influences, drug knowledge, social skills, and communication skills; utilized discussion, homework, video, role-play, behavioral rehearsal, and reinforcement 7th-graders 20-session life skills training using classroom teachers versus peers; 10 boosters in 8th grade; 7th-graders (urban, Hispanic) 15-session life skills training using classroom teachers 6th- & 7th-graders 20 sessions focusing on stress management, self-esteem, problem solving, substance and health information, assertiveness and social networks; involves discussion, role-play, diaries, and video tapes; conducted by classroom teachers and health educators Pre post Significantly lower experimental smoking among life skills training group than no-treatment controls Pre post Reduced tobacco use; increased knowledge of (3 years) smoking consequences; decreased normative expectations regarding smoking Reduced cigarette, alcohol, and marijuana use; decreased normative expectations; increased substance use knowledge; increased interpersonal and communication skills (1 year) Reduced tobacco, alcohol, and marijuana use in peer-led sessions with boosters and for females in teacher-led condition; increased tobacco knowledge and anti-smoking attitudes Pre post Reduced cigarette use, decreased normative expectations regarding peer and adult smoking; increased smoking knowledge Pre post Increased social adjustment and coping skills; intentions to use substances remained same for intervention students, but increased for controls; program effects on alcohol use but not reported drug use (cont.) 58

15 Table 3.5. (Continued) Investigator(s) Subjects Intervention approach Evaluation design Results Botvin et al. (1994); Life Skills Training Botvin, Baker et al. (1995); Life Skills Training Botvin, Schinke et al. (1995); Life Skills Training Botvin et al. (1997); Life Skills Training Botvin et al. (1999); Life Skills Training Botvin et al. (2000); Life Skills Training 7th-graders (urban, minority) 15-session life skills training using classroom teachers; 10 boosters in 8th grade; comparisons were made between generic skills training versus culturally focused condition that utilized multicultural myths and stories to model various skills 7th-graders 15-session life skills training using classroom teachers; 10 boosters in 8th grade; 5 boosters in 9th grade (same as Botvin et al., 1990) 7th-graders (urban, minority) 7th-graders (urban, minority) 7th-graders (urban, minority girls) 15-session life skills training using classroom teachers; 10 boosters in 8th grade (same as Botvin et al., 1994) 15-session life skills training using classroom teachers 15-session life skills training using classroom teachers; 10 boosters in 8th grade 7th-graders 15-session life skills training using classroom teachers; 10 boosters in 8th grade; 5 boosters in 9th grade (same as Botvin et al., 1990) (1 year) (6 years) (2 years) Both programs reduced intentions to drink alcohol; generic program reduced intentions to use illicit drugs; increased anti-drug attitudes; decreased risk-taking Reduced drug and polydrug use; strongest effects for those receiving a more complete version of the program Reduced current alcohol use and intentions to drink alcohol; increased drug refusal skills Pre post Reduced smoking, alcohol, marijuana use, and polydrug use; increased smoking knowledge; decreased normative expectations (1 year) (6.5 years) Reduced initiation of smoking and reduced escalation to monthly smoking Reduced overall illicit drug use; reduced use of hallucinogens, heroin, and other narcotics

16 Drug Abuse Prevention Curricula in Schools 60 having neutral (26%) or negative effects on behavior (11%) with several in the neutral category having inadequate statistical power to detect program effects (Hansen, 1992). Furthermore, several follow-up studies of resistance skills interventions reported positive behavioral effects lasting up to 3 years (Luepker et al., 1983; McAlister et al., 1980; Telch et al., 1982). However, data from several longer term follow-up studies indicate that these effects gradually decay over time (Murray et al., 1988; Flay et al., 1989), suggesting the need for ongoing intervention or booster sessions. The most popular and visible school-based drug education program based on the socialinfluence model is Drug Abuse Resistance Education, or Project dare. The core dare curriculum, typically provided to children in the fifth or sixth grades, contains elements of information dissemination, affective education, and social-influence approaches to drug abuse prevention. dare is distinguished by its use of trained, uniformed police officers in the classroom to teach the drug prevention curriculum. Despite the popularity of dare, its effectiveness has been called into question over the past several years. Some evaluation studies of dare reported a short-term positive impact on drug-related knowledge, attitudes, or behavior (e.g., Becker, Agopian, & Yeh, 1992). However, many outcome studies have limited scientific value because of weak research designs (such as post-test only), poor sampling and data collection procedures, inadequate measurement strategies, and problems in data analysis approaches (Rosenbaum & Hanson, 1998). Several recent evaluations of dare, using more scientifically rigorous designs (such as large samples, random assignment, and longitudinal follow-up), indicate that dare has little or no impact on drug use behaviors, particularly beyond the initial post-test assessment (Clayton, Cattarello, & Johnstone, 1996; Dukes, Ullman, & Stein, 1996; Ennett, Rosenbaum, et al., 1994; Ennett, Tobler, et al., 1994; Rosenbaum et al., 1994; Rosenbaum and Hanson, 1998). Regarding the history of dare evaluation studies, Rosenbaum and Hanson (1998) point out that the stronger the research design, the less impact researchers reported in terms of effects of dare on drug use measures. Although the reasons for dare s lack of impact are unclear, some possibilities are that dare targets the wrong mediating processes (Hansen & McNeal, 1997), that the instructional methods are less interactive than those of more successful prevention programs, and that teenagers may simply tune out what may be perceived as an expected message from an ultimate authority figure. Beyond Social Influences COMPETENCE-ENHANCEMENT APPROACHES An implicit assumption of both the psychological inoculation and resistance skills approaches is that adolescents do not want to smoke, drink, or use drugs. That is, they begin to use one or more of these substances either because they succumb to the persuasive messages targeted at them or because they lack sufficient skills to resist social influences to use drugs. A limitation of the social-influence approach is that it does not consider the possibility that some adolescents may actually want to use drugs. For some adolescents, using drugs is not a matter of yielding to peer pressure but has an instrumental value. Drugs, for example, may help them deal with anxiety, low self-esteem, or discomfort in social situations. In fact, the etiology literature indicates that drug use and abuse have a complex set of determinants, including a variety of cognitive, attitudinal, social, personality, pharmacological, and developmental factors (Baumrind & Moselle, 1985; Blum & Richards, 1979; Jessor & Jessor, 1977; Jones & Battjes, 1985; Kandel, 1978; Meyer & Mirin, 1979; Newcomb & Bentler, 1988; Wechsler, 1976). Given this, it seems logical that the most effective prevention strategy would be one that is comprehensive, targeting a broad array of etiologic determinants.

17 61 Gilbert J. Botvin and Kenneth W. Griffin Toward Generic Skills Training Approaches Among the more comprehensive approaches to drug abuse prevention are competenceenhancement approaches that emphasize generic personal and social skills in combination with resistance skills. This strategy is more comprehensive than the resistance skills training approaches and earlier cognitive/affective approaches and has been used for nearly 2 decades (Botvin, Baker, Botvin, et al., 1984; Botvin, Baker, Dusenbury et al., 1995; Botvin, Baker, Filazzola, & Botvin, 1990; Botvin, Baker, Renick et al., 1984; Botvin, Dusenbury, Baker, James-Ortiz, Botvin, & Kerner, J., 1992; Botvin, Epstein, Baker, Diaz, & Williams, 1997; Botvin, Eng, & Williams, 1980; Botvin, Renick, & Baker, 1983; Pentz, 1983; Botvin, Schinke, Epstein, & Diaz, 1994; Botvin, Schinke et al., 1995; Gilchrist & Schinke, 1983; Kreutter, Gewirtz, Davenny, & Love, 1991; Schinke, 1984; Schinke & Gilchrist, 1983, 1984). The theoretical foundations for the competence-enhancement approach are Bandura s social learning theory (Bandura, 1977) and Jessor s problem behavior theory (Jessor & Jessor, 1977). According to this approach, drug abuse is conceptualized as a socially learned and functional behavior that is the result of an interplay between social (interpersonal) and personal (intrapersonal) factors. Drug use behavior is learned through a process of modeling, imitation, and reinforcement and is influenced by an adolescent s pro-drug attitudes and beliefs. These factors, in combination with poor personal and social skills, are believed to increase an adolescent s susceptibility to social influences in favor of drug use. Methods. Although these approaches share several features with resistance skills training approaches, a distinctive aspect of competence-enhancement approaches is an emphasis on generic personal self-management skills and social skills. These skills are taught using a combination of proven cognitive behavioral skills training methods: instruction and demonstration, group feedback and reinforcement, behavioral rehearsal (in-class practice), and extended (outof-class) practice through behavioral homework assignments. Examples of the kind of generic personal and social skills typically included in this prevention approach are decision-making and problem-solving skills; cognitive skills for resisting interpersonal and media influences; skills for enhancing self-esteem (goal-setting and self-directed behavior-change techniques); adaptive coping strategies for dealing with stress and anxiety; general social skills (complimenting, conversational skills, and skills for forming new friendships); and general assertiveness skills. This prevention approach teaches both these general skills and their application to situations directly related to tobacco, alcohol, and drug use. An added benefit of this type of program is that it teaches adolescents a repertoire of skills they can use to deal with many of the challenges confronting them in their everyday lives, including but not limited to drug use. By teaching generic coping skills that will have broad application, this approach contrasts markedly with resistance skills training approaches designed to give students information and skills relating solely to drug use. However, the most effective approaches appear to integrate features of both generic coping skills and drug-specific resistance skills. In fact, there is some evidence that generic skills training approaches are only effective if they also contain drug-specific material (Caplan et al., 1992). Effectiveness. Over the years, a number of evaluation studies have tested the efficacy of competence-enhancement approaches to drug abuse prevention. These studies consistently demonstrated behavioral effects as well as effects on hypothesized mediating variables. Importantly, the magnitude of the effects of these approaches has been relatively large, with studies reporting reductions in drug use behavior in the range of 40 to 80%. A criticism of contemporary

18 Drug Abuse Prevention Curricula in Schools 62 prevention programs is that even though they produce impressive reductions in the incidence and prevalence of drug use behavior, these reductions generally occur with respect to experimental or occasional use. However, in addition to demonstrating reductions in the early stages of drug use, it is important to demonstrate reductions in more frequent levels of use, such as the kind of regular use that leads to addictive or compulsive patterns of use. Findings from two studies of a competence-enhancement prevention program called Life Skills Training (Botvin, 1996) deal directly with this issue by demonstrating reductions in rates of regular cigarette smoking. Two studies have shown reductions of 56 to 67% in the proportion of pretest nonsmokers becoming regular smokers 1 year after the conclusion of the program without any additional booster sessions (Botvin & Eng, 1982; Botvin, Renick, & Baker, 1983). For those students receiving booster sessions, the reductions have been as high as 87% (Botvin et al., 1983). Results of studies using competence-enhancement approaches like Life Skills Training have also demonstrated an impact on other forms of drug use, including alcohol use (Botvin Baker, Botvin, et al., 1984; Botvin, et al., 1990; Botvin, Baker, Renick, et al., 1984; Botvin, Schinke, Epstein et al., 1995; Pentz, 1983); marijuana use (Botvin, Baker, Botvin, et al., 1984; Botvin, Baker, Dusenbury et al., 1990, 1995), and poly-drug use (Botvin, Baker, Dusenbury et al., 1995, Botvin, Epstein, Baker, et al., 1997). These reductions have generally been of a magnitude equal to that found with cigarette smoking. Finally, long-term follow-up data indicate that the prevention effects of these approaches can last for up to 6 years (Botvin Baker, Dusenbury et al., 1995; Botvin et al., in press). In summary, drug abuse prevention programs that emphasize resistance skills and general life skills (such as competence-enhancement approaches) appear to show the most promise of all school-based prevention approaches. ISSUES IN SCHOOL-BASED PREVENTION Despite the substantial gains in school-based drug abuse prevention over the past couple of decades, a number of important issues remain with regard to the development, implementation, evaluation, and dissemination of prevention interventions in schools. Program Development Timing of Interventions. Research on the age of onset and developmental progression of drug use indicates that the initiation of drug use tends to follow a logical and predictable sequence (Hamburg, Braemer, & Jahnke, 1975; Kandel, 1975). Most youths begin by experimenting with alcohol and cigarette smoking, followed later by the use of marijuana. A subset of these individuals will progress to the use of depressants, stimulants, hallucinogens, and other dependency-producing drugs. This progression of drug use initiation suggests that the focus of early-prevention interventions should be on drugs early in the developmental progression (cigarettes, alcohol, and marijuana), which typically begin to be used during the middle/junior high school years. Not surprisingly, the vast majority of published studies have involved students in junior high, with students typically in the seventh grade during the first year of intervention. However, a criticism of school-based drug abuse prevention programs is that they typically do not acknowledge that different individuals may have different levels of programmatic needs (Institute of Medicine, 1996) and that one school prevention program may not be adequate for all children and adolescents. To address this concern, three types of prevention tiers have been used in categorizing prevention interventions since the early 1990s: universal, selective,