Identification of Drug Abuse Prevention Programs

Literature Review

Sections
- Introduction
- Purpose
- Types of Prevention Interventions
- Part A - Universal School-Based Prevention Programs
- Part B - Selective School-Based Prevention Programs

Part C - Indicated School-Based Prevention Programs:
   - Mixed Comprehensive Prevention Approaches

- Comparison of Effectiveness of Different Prevention Approaches
- Summary of Results of Effectiveness Studies
- References

Indicated Prevention Programs

Indicated prevention programs are designed for students who are already manifesting identified risk factors for drug use/abuse, such as poor school achievement, school dropout, association with antisocial and gang-involved peers, and aggressive or conduct disorders. Because enduring early childhood behaviors, such as conduct disorders, anxiety, and aggression, have been found to be stable precursors of later drug use and delinquency (Hinshaw et al., 1993; Loeber, 1990), indicated prevention programs in schools and communities are needed. A number of highly effective, small-group prevention programs are being developed for preschool or elementary school youth who are identified by their teachers as aggressive or having conduct disorders. These indicated prevention programs are generally even longer and more intensive than selective prevention programs and are conducted only with identified youth with diagnosed or identified behavioral, emotional, or academic problems. The level of professional training is generally even higher for staff working with these indicated populations of youth and families.

Indicated programs have advantages that are similar to selective programs; they enhance the appropriate targeting of often limited prevention resources. They are more intensive in dosage and directly address risk factors that are already manifest, such as conduct disorders, aggression, shyness, anxiety, and lack of social and life skills.

Because prevention efforts are being targeted to youth who are already exhibiting identified risk factors, indicated programs have few disadvantages. Disadvantages are that these more intensive programs frequently require highly trained staff, possibly with clinical or counseling backgrounds. Without sufficient training in managing group behaviors and norms, a negative contagion effect can occur (Dishion & Andrews, 1995), leading to iatrogenic effects or reduced effectiveness over mixed groups or family groups.

These include Lochman's Anger Coping Program and Coping Power Programs (Lochman & Wells, 1996), Shure's I Can Problem Solve Program (Shure, 1992a, 1992b; Shure & Spivack, 1973), Social Skills Training in the Fast Track Program (Bierman, Greenberg, and the Conduct Problems Prevention Research Group, 1996), Kazdin's Problem Solving Social Skills Training Intervention Program (Kazdin, 1995; Kazdin, Esveldt-Dawson, French, & Unis, 1987), and Eggert's Reconnecting Youth Program with its Personal Growth Class for high school students at risk of dropping out of school (Eggert et al., 1994). Only this final program is highlighted in the NIDA (1997) publication and is described in more detail below.

Reconnecting Youth Program (Eggert, Thompson, Herting, & Nicholas, 1994, 1995; Eggert et al., 1994) is an indicated prevention program for high school students who are at risk for dropping out of school because of declining grades or other behavioral or mental problems such as substance abuse, depression, or suicidal ideation. The program's Personal Growth Class involves students in a credit class that provides a peer support group and teaches social and life skills that increase resilience to drug use. The program also involves promotion of drug-free social activities and friendships and a School System Crisis Response Plan for dealing with suicidal students. The research results demonstrate that students participating in this program sho÷ significant improvements in school performance, self-esteem, personal control, school bonding, and social supports, while reducing depression, anger and aggression, hopelessness, stress, suicidal behaviors, and drug involvement.

These are indicated prevention approaches for drug users or individuals showing mental health symptoms of risk (e.g., delinquency, aggression, depression, and other antisocial behavior). These strategies involve problem identification, screening, and referrals to special therapeutic programs designed to help reduce the presenting problems. Examples include student assistance programs, peer counseling programs, parent-peer groups for troubled youth, teen hotlines, and crisis intervention (Morehouse, 1979; Morehouse, Tobler, & Kleinman, 1995; Tobler, 1986, 1992).

Some of the most effective family-based programs for indicated prevention include Szapocznik'sStructural Family Therapy, Alexander and Parson's Functional Family Therapy, Gordon's Home-Based Functional Family Therapy, Henggler's Multi-Systemic Family Therapy, and Forehand and McMahon's behavioral family therapy program (for reviews see prior Web site or CSAP/Family PEPS, in press).

Table 4: Types of indicated school-based prevention programs

Sections

Mixed Comprehensive Prevention Approaches

Some schools or communities use a mixture of all three approaches to prevention. These comprehensive approaches frequently involve a community planning and development approach, with local solutions developed by planning committees matched to needs assessment data on risk and protective factors.

The advantage is that all three types of youth and families receive prevention programs specifically targeting their major risk and protective factors. These programs include locally designed solutions based on research-based models or sometimes involving new approaches.

The disadvantages of mixed comprehensive approaches are that they require significant fiscal and staff resources, take significant amounts of school and community readiness and commitment to implement, are volunteer and staff intensive, and require a prevention director to coordinate the many different prevention programs. Also, an effective planning process cannot proceed without needs assessment data on risk and protective factors. A school or community survey may need to be conducted before services are planned.

These include the School Transitional Environment Project (STEP) (Felner et al., 1993), which is a school climate change program; the Aban Aya Project in Chicago (Flay, 1997); Project PATHE (Gottfredson, 1986) and its variant targeted for universal, high-risk, and in-crisis youth through a comprehensive student and community team approach; and Project HI PATHE (Kumpfer et al., 1991), which included interventions for universal, at-risk, and in-crisis students.

This school-based approach is unique because in each site the program activities are planned locally by teams of students, teachers, administrators, parents, and community members based on the Program Development Evaluation model (Gottfredson, 1986; Gottfredson & Gottfredson, 1989; Kumpfer et al., 1991)). The activities are designed by the school teams after a review of local school needs assessment data (Kumpfer & Turner, 1990/1991) and often include a mixture of universal school activities (i.e., school policy revisions, school pride days, plays and assemblies, educational reform with cooperative learning training for teachers combined with universal health promotion and substance abuse prevention curricula, and parent training); selective school activities (i.e., children of alcoholics groups, minority youth after-school programs, buddy programs, and welcome wagons for transferring students); and indicated activities (i.e., student hotlines run by peers with professional training and support, treatment aftercare groups at school, in-school suspension for suspended students, and tutoring and mentoring for students performing poorly academically). Unfortunately, because of the short-term nature of Project HI PATHE's funding from DOE, the evaluation results were not conclusive (Kumpfer et al., 1991). However, because of the effectiveness of this approach as demonstrated by Gottfredson (1986), including changes in substance abuse rates as well as problem behaviors, this school climate approach is worthy of additional research.

Few comprehensive family approaches exist that involve the universal, selective, and indicated approaches together, because family approaches tend to be more tailored to one specific family population. One example of a multicomponent approach is the Adolescent Transitions Program (Dishion et al., 1996), which provides through schools a family resource room available to all families, selective family services, and more intensive family services to youth identified with conduct disorders and aggressive behaviors. The ten new CSAP Developmental Predictor Variable grants are conducting research on the effectiveness of providing comprehensive prevention services to all students in schools, to selective families, and to indicated youth and families.

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Comparison of Effectiveness of Different Prevention Approaches

In general, meta-analyses of the outcome effectiveness results suggest that the most effective approaches are those involving behavioral skills training (i.e., social influence approaches, life and social skills, and behavioral parent training and family skills training), rather than the drug education, affective education, or alternative approaches (Hansen, 1992; Lipsey, 1992; Tobler, 1986; Tobler & Stratton, 1997). Hansen (1992) found that comprehensive and social influence programs were the most successful in preventing the onset of substance abuse. Tobler and Stratton (1997) found that interactive programs involving youth were more effective than didactic programs that lecture or provide information to youth.

Kumpfer's(1994b, 1997c) analysis of family programs for the prevention of substance abuse and delinquency supports these same principles of effective approaches. Behavioral parenting programs and family skills training programs are more effective than parent education programs that involve lectures. Behavioral skills training programs are highly structured and involve direct practice with the trainers in the sessions, corrective feedback, commitments for behavioral change, group pressure to change, and reinforcements for completion of homework and behavioral change outside the group.

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Summary of Results of Effectiveness Studies

The most effective prevention programs are tailored to the most salient risk and protective factors for a particular group. Making the currently effective programs more gender-, age-, and culturally appropriate should increase impact as well as attractiveness to youth. Although many promising approaches are discussed in this review, only a few approaches have demonstrated outcome results - namely, skills-training approaches based on social learning theory. This includes children's social or life skills training and parent or family skills training. There is suggestive evidence (Kumpfer, Molgaard, & Spoth, 1996) that combining parent or family training with youth social skills training provides the most powerful combination (for reviews of many combined programs, see Kumpfer, 1994b, 1997c). Additionally, Dishion and Andrews (1995) found that aggregating high-risk youth in a youth-only skills training group can have iatrogenic effects compared to the positive effects of a parent-training-only or combined approach.

This review also makes it more apparent that the most highly marketed and most implemented prevention programs for drug abuse prevention are not the most effective research-based programs (Kumpfer, 1997a; Lerner, 1995; Tobler & Stratton, 1997). The most effective prevention programs are those that are frequently implemented to conduct research on their effectiveness. Unfortunately, they also tend to lose funding at the ending of the grant period and are rarely disseminated and replicated (Lerner, 1995). For example, Schorr (1988) found that 1 year after her review, only 50% of the successful programs still existed. Many state substance abuse authorities and federal agencies (e.g., NIDA, NIAAA, and CSAP) are making major efforts to support the dissemination of those research-based prevention programs. The failure to do so means that most of the youth in this country are being exposed to prevention approaches that are ineffective or counterproductive. According to Norman and Turner (1993), approaches that have the potential to be counterproductive include interventions based on information models only and some types of alternative activities as found earlier by Swisher and Hu (1983). Tobler and Stratton's (1997) most recent analysis of prevention programs supports wide variations in school prevention program effectiveness. The most effective strategies were those that were more interactive in delivery rather than didactic. Although prevention specialists in many different areas of youth and family problems have evidence of effectiveness in their fields, what appears to be needed are principles of prevention that are effective across many problem-specific prevention areas.

What we have learned about effective prevention programs for substance abuse prevention is clear. There is no one best prevention program, and no one program or approach will stop all drug use. There are many effective research-based programs available to choose from; however, the best approach for any particular population will require selecting the best intervention for the target population based on knowledge of the risk and protective factors in that population. Unfortunately, the most highly marketed school or family programs are generally not those with the best outcome effectiveness results. Evaluation results need to be available. Increased knowledge and changed attitudes are not sufficient - behavioral changes in risk precursors and actual drug use are needed. Additionally, implementation and community readiness variables must be considered when selecting the best prevention program for the local community. Help in these areas can be found in Wandersman and associates (in press), Comprehensive Quality Programming: Eight Essential Strategies for Implementing Successful Prevention Programs, and Kumpfer, Whiteside, and Wandersman (1997), Assessing and Enhancing Community Readiness for Prevention.

The best approach to prevention is to begin early to reduce emerging behavioral and emotional problems in youth. Longer-lasting effects should accrue from changing school, community, and family environmental conditions that promote and maintain drug problems in youth. More and more prevention specialists are considering moving from a focus on the individual to changes in total systems or the environmental contexts that promote or hinder drug use. Based on economic considerations, the "whole family" systems change approach of family skills training classes is even becoming popular in the managed care environment (Stoil & Hill, 1996).

The greatest challenge facing the drug abuse prevention field is disseminating information to practitioners about the best prevention programs, approaches, and principles of effectiveness. Researchers and funding agencies must learn how to market effectively the most successful programs to better bridge the gap between research and practice. We must become as effective at marketing drug prevention programs as are drug dealers at promoting and selling drugs. Drug sales are promoted through highly effective multilevel marketing strategies with major economic and social incentives for becoming a drug dealer. If the prevention field does not become equally effective marketers of healthy lifestyles, we will continue to lose ground in the fight to reduce drug abuse in youth in this country.

Sections

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