Kouimtsidis C., Reynolds M., Coulton S. et al.
Drugs: Education, Prevention and Policy: 2011, early online publication.
Request reprint using your default e-mail program or write to Dr Kouimtsidis at drckouimtsidis@hotmail.com

Compromised by an inability to interest enough patients, the only randomised UK trial of cognitive-behavioural therapy for methadone patients was unable to be definitive but did find some signs of benefit and that the therapy had pulled some of the intended psychological levers.

Summary Cognitive approaches to treating substance misuse problems are still relatively new and it is important to understand how they work. Relevant treatment models emphasise the role of: self-efficacy to cope with situations associated with drug use without using; developing skills to cope with these situations as well as skills to generate broader lifestyle changes; and changing patients’ expectations of the positives and negatives of using the substance. Successful treatment is theorised to result from a reduction in the extent to which patients expect positive outcomes from substance use, an increase in their negative expectations, and enhanced self-efficacy and coping skills.

The featured study was the first study to directly test this model in the context of substitution treatment for opiate dependence. The findings derive from the UKCBTMM United Kingdom Cognitive Behaviour Therapy Study In Methadone Maintenance Treatment. study, which investigated the effectiveness and cost-effectiveness of cognitive-behavioural therapy for patients in opiate substitute prescribing programmes, itself the first randomised controlled trial of a psychosocial intervention in this setting in the UK.

At several UK treatment centres, the study randomly allocated substitute prescribing patients to keyworking only or keyworking plus cognitive-behavioural therapy, and assessed whether the additional therapy improved outcomes six and 12 months later. Additional therapy was offered weekly for 24 weeks but typically patients attended only four sessions. Therapists and keyworkers were recruited from existing staff and the therapists were trained and supervised in the therapy.

Perhaps because so few patients were eligible for and prepared to join the trial (just 60 did so of 369 who were eligible), though there were outcome gains from the extra therapy, none were statistically significant. Nevertheless, as measured by their effect sizes, A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen’s d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. In the featured study effect sizes were expected to be about 0.3. the gains were as large as expected in terms of reductions in the severity of addiction and heroin use, and improved compliance with prescribed methadone use. The cost of the extra therapy was more than outweighed by savings in health, social, economic, work, and criminal justice costs. Perhaps because patients had already been in methadone treatment for on average five months, these savings were less than in some other studies, and the difference in cost savings between therapy and non-therapy groups was not statistically significant.

Main findings

However, the featured report was less concerned with whether extra cognitive-behavioural therapy improved the end result of methadone treatment, than with how it might have done so. One way was expected to be by improving how well patients coped with life’s problems, a concept measured by a standard questionnaire which assessed different aspects of this ability. Relative to keyworking only, as expected, at six months the therapy was followed by a significant improvement in the degree to which patients positively reappraised problems, and a non-significant improvement in problem solving. Other domains where additional improvements were expected (logical analysis, seeking guidance and seeking alternatives) improved to roughly the same degree regardless of the extra therapy. Six months later (and 12 months after therapy had started) a similar analysis revealed that nearly all the expected mechanisms had improved after cognitive-behavioural therapy but deteriorated without it. The exception was logical analysis, where the reverse pattern was seen. Despite these trends, none of differences between patients who had or had not been offered cognitive-behavioural therapy were statistically significant, so chance variation could not be ruled out.

As expected, the degree to which patients felt confident that they could resist the urge to use drugs (‘self-efficacy’) increased after cognitive-behavioural therapy but decreased (at six months) or increased less (at 12 months) without this therapy. Patients were also asked about the good and bad consequences they expected from cutting down their heroin use. These measures changed in the opposite to what was expected; patients offered the therapy became relatively less positive and more negative about cutting down. Again, none of these differences between the two groups of patients were statistically significant.

Further analyses not reported here assessed changes among only patients who attended at least one session of their intended psychosocial intervention and related changes to the number of therapy sessions attended.

The authors’ conclusions

Though no definite conclusions can be taken from this study, there are indications that the therapy may be effective through at least some of the intended mechanisms, but also that methadone-maintained patients at services as configured in England in the 2000s generally reject the chance for this form of extra therapy.

The fact that few patients were prepared to join the study and that those who did attended few therapy sessions suggest there could be major barriers to implementing cognitive-behavioural therapy in routine practice in the British drug treatment system, perhaps associated with a culture of limited psychological therapy and relatively low expectations of clients’ engagement and compliance with treatment.

With such a small sample there is a heightened possibility that real differences made by the therapy will fail to meet conventional criteria for statistical significance and be mistakenly dismissed as chance variation. That this might have happened is suggested by the fact that the relative increase in days free of heroin use after six months was as great as expected. With a larger sample, it might well have also proved statistically significant. Economic analyses also found non-significant but appreciable net social cost-savings. The featured analysis supplements these outcome findings with indications that cognitive-behavioural therapy may have fostered some but not all of the crucial problem-solving skills.

The main seemingly counter-productive finding related to expectations about the pros and cons of reducing heroin use as measured by a scale yet to be validated. Also, more sessions of therapy did not further enhance the presumed psychological mechanisms through which the therapy worked. Nor were these mechanisms significantly related to substance use and other outcomes – again, perhaps due to the small sample size.

While appreciating the limits set by sample size, the non-significant trends suggesting that the therapy worked though the intended mechanisms were generally small in size. Of 22 comparisons between the two sets of patients, in only one had a mechanism (positively reappraising life’s problems) changed to a statistically significant degree in the expected direction – a result to be expected purely by chance. Together with a few counterproductive trends, these minor changes in the mechanisms thought to be specific to cognitive-behavioural therapy do not suggest it has a special role (that is, over and above other forms of psychological therapy) as a supplement to routine keyworking in the circumstances of the trial. At the same time the findings suggest that extra therapeutic contact did help stabilise patients who were prepared to accept it. Whether this needed to be cognitive-behavioural or a recognised therapy of any kind is impossible to tell from the study. Broader research offers little support for a distinctive role in addiction treatment for cognitive-behavioural approaches, results from which are generally equivalent to other approaches. It also seems that, at least in the mid 2000s, a steep hill remained to be climbed before formal psychological interventions of any kind were routinely and expertly implemented inBritain’s methadone clinics. How far that has changed is unclear. Details below.

CBT in methadone treatment

Guidelines from Britain’s National Institute for Health and Clinical Excellence (NICE) recommend cognitive-behavioural therapy not as a routine means of further stabilising patients, but to help with lingering anxiety and/or depression among those already stabilised in maintenance treatment. However, the analyses which led NICE to counsel against routine use did not show that cognitive-behavioural therapy was ineffective, just that it was not convincingly more effective than other well structured therapies.

Published in 2007, these guidelines did not have available to them the latest update of an authoritative meta-analytic A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention’s effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. review conducted for the Cochrane collaboration which combined results from studies comparing structured psychosocial interventions against normal counselling among methadone and other opiate substitution patients. Taking in new studies available up to 2011, it found that overall such interventions had improved neither retention nor outcomes (including opiate use) to a statistically significant degree. In particular, the same was true of the family of behavioural interventions including cognitive-behavioural therapy. Contrary to expectations, this update found contingency management conferred no significant benefits, contradicting both its earlier findings and the NICE guidelines referred to above.

In the Cochrane review, verdicts in respect of cognitive-behavioural therapy rested on three studies, one of which does not appear to have reported substance use outcomes but did find greater improvements in psychological health. Relative to drug counselling alone, so too did a study of male US ex-military personnel starting methadone treatment. A year later, in this study cognitive-behavioural patients had improved more on a much wider range of psychological, social and crime measures, but not in respect of substance use. From methadone plus routine drug counselling only, so complete were the reductions in opiate use that little space was left for additional therapy to further improve outcomes. These two US studies are supplemented by a German study which found that group cognitive-behavioural therapy led to significantly greater post-therapy reductions (at the six-month follow-up) in drug use than routine methadone maintenance alone. The effect was largely due to changes in cocaine use, but there were also minor extra improvements in abstinence from opiate-type drugs and benzodiazepines. What these three studies suggest is that offering extra psychotherapy (not necessarily cognitive-behavioural therapy in particular) improves psychological and social adjustment and perhaps too helps reduce non-opiate substance use, but that methadone maintenance itself as implemented in these studies was such a powerful anti-opiate use intervention that further gains on this front were harder to engineer.

CBT in substance use treatment generally

If in terms of core substance use outcomes, cognitive-behavioural therapy in methadone maintenance does little to improve on routine counselling, this will simply be in line with findings in respect of the therapy’s role in treating drug and alcohol problems in general. A review combining results from relevant studies suggested that it remains to be shown that cognitive-behavioural therapies are more effective than other similarly extensive and coherent approaches. Studies which directly tested this proposition often found little or no difference, even when the competing therapy amounted simply to well structured medical care.

The implication is that choice of therapy can be made on the basis of what makes most sense to patient and therapist, availability, cost, and the therapist’s training. In respect of cost and availability, cognitive-behavioural therapy may (more evidence is needed) prove to have two important advantages. The first is that effects may persist and even amplify without having to continue in therapy. The second is that it lends itself to manualisation to the point where it can be packaged as an interactive computer program and made available in services lacking trained therapists – potentially a crucial advantage for widespread implementation.

Will CBT help methadone patients leave treatment?

Beyond core substance use outcomes is what in Britain is now a priority issue – whether more intensive therapy, even if it seems to add little to the powerful opiate use reduction effect of methadone treatment, might help people gain sufficient psychological and social stability to leave this treatment, and leave it sooner. In respect of psychotherapy in general and cognitive-behavioural therapy in particular, this remains a live possibility with some support from studies of during and post-treatment changes, though none have directly tested whether these enable patients to more safely leave the shelter of substitute prescribing programmes.

However, from the starting point revealed by the featured study, there seems a long way to go before structured psychosocial interventions of any kind are routine in Britain’s methadone services. An earlier report from the study commented that services were overstretched and understaffed and suffered from high staff turnover. Very few staff had been trained in psychological interventions and sometimes even basic individual client keyworking was extremely limited. Difficulties in engaging clients in the study were attributed partly to a low level of psychological interventions in services, which in turn led to low expectations of clients engaging with these interventions. Perhaps too, the authors speculated, some clients were reluctant to become involved in more intensive treatment or to address psychological issues not previously identified in usual clinical care. Most tellingly, the researchers observed “a nihilistic view of psychological intervention and clients’ capacity for change among some staff”.

In this climate, and with the added burden of research procedures, the small proportion of patients prepared to accept therapy and attend more than a few sessions is likely to be an underestimate of the possible caseload if cognitive-behavioural therapy were well promoted as a part of usual care, especially if elements of the approach were incorporated in keyworking rather than offered as an optional add-on.

In a different set of services probably sampled in the mid-2000s, perfunctory brief encounters focused on dose, prescribing and dispensing arrangements, attendance records, and regulatory and disciplinary issues characterised the keyworking service offered by some British criminal justice teams to offenders on opiate substitute prescribing programmes. However, ‘relapse prevention’ was the most common therapeutic activity in the sessions, featuring in 44% of the last sessions recalled by the staff, a term often taken to imply cognitive-behavioural approaches. What staff included under this heading was unclear, and the time given to it averaged just seven minutes, but is does suggest that there is a platform which could be built on. Unfortunately the need to do this building to foster recovery and treatment exit has coincided with resource constraints which make widespread training in and implementation of fully fledged therapy programmes seem unlikely.

Thanks for their comments on this entry in draft to Christos Kouimtsidis of the Herts Partnership NHS Foundation Trust in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 16 December 2011

Source: www.findings.org.uk

Written by Bonnie Benard, NIDA, USA.(Originally in training manuals for Project Snowball, Illinois Teen Institutes, 1987)

Published in Britainin ‘Drug Prevention – Just say Now’ by Peter Stoker, pub. David Fulton Publishers,London, 1992.

Programme comprehensiveness/intensity

A.        Multiplicity: the causes of drug/alcohol abuse are multiple: personality, environmental, behavioural (Kandel, Logan, 1984; Hawkins et al, 1951).  Programmes tackling only one area usually fail.  You should target multiple systems (youth, families, schools, community, workplace, media, etc).  Also use multiple strategies (information, lifestyles, positive alternatives, community policies) (Botvin, 1982).

B.         Target whole community.  School-based programmes achieve less than community-based approaches.

C.         Target all youth for prevention – not just “high risk”.  Adolescence is seen to be a high-risk time for all youth in terms of health-compromising behaviour.  Labelling “high risk” youth can provoke stigmatisation and lead to self-fulfilling prophecies.  There is however an argument for defining “high risk” communities where an additional resource over and above the general prevention effort could be justified.

D.        Build drug prevention into general health promotion.  Drug abuse has been found by several (Lofquist, 1993) to be part of a complex pattern of interrelated factors – e.g. delinquency, truancy, school failure, precocious sexuality, which share common antecedents.

E.         Start at an early age and keep going!  Even in infancy there are influences in later behaviour.  Developmental difficulties by age 3 are difficult to overcome (Burton, White).  Here, it is of course relevant to mention Trevor Williams, Noreen Wetton and Alysoun Moon of the Southampton University team who have demonstrated so graphically in their “Jugs and Herrings” research papers that primary age children are not blissfully ignorant of drugs and alcohol.  Prevention programmes starting from what children actually know are essential.  Many secondary schools still seem to regard years 11 and 12 as the age at which discussion of drugs (or indeed sexuality) should be facilitated.  Don’t wait until the horse has run away before you lock the stable doors!

F.         Adequate quantity.  ‘One-shot prevention efforts do not work” (Kumpfer, 1988) there must be a substantial number of interventions, each of a substantial duration.  Project D.A.R.E. (Drug Abuse Resistance Education) initiated by Los Angeles Police and now in several countries, delivers no less than seventeen one-hour lessons to any given year and this is only part of the school programme.

G.        Integrate family/classroom/school/community life.  This is easier to say than do, but where it has happened results have been enhanced.

H.        Supportive environment, empowerment.  Where young people are encouraged to participate and take responsibility their behavioural outcomes are improved.  InBritain now peer-education methods which have been proven elsewhere have been applied to good effect.

Programme strategies

J.          ‘KAB’ - Knowledge/Attitudes/Behaviour.  Address these as a set, i.e. each must be directly tackled rather than assuming one will flow from another.  The behavioural component is in part addressed by social skills development, but also supported by positive reinforcement activities – drug free social/sporting events, commendations (preferably with something for everyone), media coverage, etc.  Research suggests that social learning theory (Bandura, 1977) produces some of the most profound improvements.

K.         Drug specific curriculum.  Affective education programmes that had not specifically covered drugs (including alcohol) were found unsuccessful, even though they addressed knowledge, attitudes and lifeskills.

L.         Gateway drugs.  So-called because people now using heavy-end drugs almost always started on these.  Gateway drugs can be tobacco, alcohol and cannabis or, these days inBritain, even heroin!  Concentration on prevention of these is therefore likely to prevent all substances.  British research by PaT (Parents against Tobacco, 1990), showed that of youth who smoked tobacco 50% had also tried an illegal drug compared with only 2% of those who did not smoke tobacco.  It should be particularly noted that cannabis is far from harmless; physical, mental and social damage is now being increasingly accepted as a reality.

M.        Salient material.  Whatever is used needs to identify with the audience, including:

•          ethnic/cultural sensitivity

•          appeal to youth’s interests

•          short term outcomes to be emphasised as important to youth as well as long term

•          appropriate language, readability

•          appealing graphics

•          appropriate to real age/reading age – a key factor

In a survey of 3, 700, 000 young American children, 25% of 9 year olds felt “some” to “a lot” of peer pressure to try drugs or alcohol (Weekly Reader, 1987).

N.        Alternatives.  Activities have to be plausible, be more highly valued than the health-compromising behaviour.  Too often these alternatives are poorly thought through. ( ‘Ping-pong = prevention’? No!)

P.         Lifeskills.      Development of these will be of wider benefit than drug prevention.  Included will be

communication, problem solving, decision-making, critical thinking, assertiveness, peer pressure reversal, peer selection, low-risk choice making, self-improvement, stress reduction and consumer awareness (Botvin, 1985).

Choosing your friends has been found in some research to be more effective than resisting the peer pressure of said friends.  Consumer awareness is a “companion” to resisting peer pressure, i.e. resisting media pressure.

Q.        Training prevention workers.  For the school setting the greater emphasis on experiential and interactive work requires teacher training to extend into youth work skills.  Community development skills are valuable in taking school initiatives into the community.  Imported “prestige” role models are all very well, but good results have been achieved with parents, peers, teachers, or outside agency workers.

R.         Community norms.  Consistency of policies throughout schools, families and communities can greatly enhance impact.

S.         Alcohol norms.  Because of its dual status as a beverage and as a culturally accepted drug, alcohol is problematic for prevention.  However, heart disease and tobacco prevention programmes have shown that societal norms can be changed.

T.         Improve schooling!  Listed here as a target because of its important correlation with healthy lifestyle.  Within the current British economic and academic climate one realistic hope may lie with co-operative learning, see the ‘Tribes’ programme, for example.

U.        Change society.  Don’t just stop with improving schools; add your voices to pressure for improvement in employment, housing, recreation and self-development; it is naïve to suppose that prevention can take place in a political vacuum.  Jessor recognises that failing to acknowledge the need for macro-environmental improvement while at the same time placing the responsibility for health solely with the individual is tantamount to “blaming the victim”.

The planning process

V.         Design, implementation, evaluation.  Evaluations have generally concentrated on outcomes rather than the quality of design.  However, implementation is as much dependent on engaging all sectors of the community (be it a school, a workplace, or a town) as it is on quality of design.  Evaluation should therefore measure process as well as outcome.

W.        Goal-setting.  Unrealistic or immeasurable goals help no-one.  It is important to set not only long-term outcome goals (for prevention is long-term) but also “process goals” such as increased involvement of parents and community, academic success, increased student-teacher interaction, and so on.

X.         Evaluation and amendment.  Prevention workers have been criticized for giving too little attention to this area, the crushing shortage of funds has much to do with it (inAmerica the ratio of funding between interdiction-policy and prevention is about 200:1).  This lack of emphasis on evaluation has been the Achilles heel that pro-drug campaigners have gleefully attacked.  Effective evaluations have been those including longitudinal design, multiple measures of process as well as outcome (Tobler, 1986), and cost-benefit analysis (CBA).  CBA is perhaps the greatest marketing tool prevention has; where CBA has been applied substantial cost effectiveness has been demonstrated.

National Drug PreventionAlliance PO Box 594, Slough  SL1 1AA   J  Tel / Fax: +44 (0)1753 677917 E-mail: NDPA@drugprevent.org.uk   J  Internet: www.drugprevent.org.uk

 

 

Volatile substance abuse can cause sudden death. Stephen Ream offers advice to youth workers on helping young people.

What is volatile substance abuse?

Volatile substances readily evaporate at room temperature, giving off a “sniffable” vapour. Volatile substance abuse (VSA) is when these substances are deliberately inhaled through the mouth and/or nose to achieve a change in mental state or “high”. The most commonly misused products are butane gas from cigarette lighter refills, aerosols (deodorants or hair sprays), petrol and some glues.
Many people assume that, because these products are legal, they are safe. In fact, inhaled volatile substances can kill suddenly and unpredictably, and there is no way to avoid this risk.

How many young people inhale volatile substances?

The cheapness and accessibility of products make younger and more vulnerable children particularly susceptible. In the annual NHS report Drug Use, Smoking and Drinking Among Young People in England, VSA continues to be the most common form of substance misuse among 11- to 13-year-olds, and second only to cannabis by the age of 15. However, we have seen the positive effects of preventive education, with usage falling from 5.5 per cent of pupils in 2009, to 3.8 per cent in 2010.
According to the annual St George’s University of London report, VSA kills about 50 people a year in the UK. In the past decade it has killed more under-15s than all illegal drugs combined.

Why do young people do it?

VSA is an enticing high for teenagers in that it is cheap, accessible and fast-acting, and a volatile substance such as butane has little or no hangover effect. VSA is often a sign of problems in other areas of a young person’s life, such as bereavement, divorce or stress. But the motivating factors might just be sheer accessibility, peer pressure, boredom or a desire to shock parents or carers.

What are the warning signs?

Like any drug, these can include mood or behavioural changes such as appearing drunk or dizzy, or seeming secretive, withdrawn, irritable, restless or inattentive. A chemical smell might be noticed, a runny nose, watery eyes, rashes or spots around the nose and mouth, throat irritation or nausea.
Environmental evidence of use might include empty gas, aerosol or glue containers with teeth marks in the nozzle, or products disappearing from around the home. At least one parent told us that it was a “family joke” how much deodorant their teenager used until they realised what was going on.
Social evidence might include truancy, poor academic performance, a new social group or isolation from previous friends, and a withdrawal from activities.

What can youth workers do?

VSA can cause cardiac arrhythmia – a problem with the rate or rhythm of a heartbeat – and kill instantly. The only way to avoid this risk is to stop.
If no advice is likely to encourage a user to stop VSA immediately, it might be appropriate to give information that helps them avoid other risks, such as: don’t do VSA alone or in dangerous or out-of-the-way places; don’t impede breathing in any way; don’t use near a naked flame or lit cigarette; and don’t drink alcohol or take other drugs. However, while these will reduce the risk of suffocation or fatal accident, the toxic effects of VSA can still kill at any point.
If you find a young person intoxicated from VSA remain calm. Do not excite them or try to use force to remove the product. Any stress or physical exertion can trigger cardiac arrhythmia.
When working with a young person engaging in VSA: strip the environment of temptations; have clear, visible policies on the use and storage of volatile substances; openly discuss the potential dangers to their health; explore carefully how and why VSA started; and arrange support from other agencies, such as generic drug services, GPs and counsellors.

Source:www.cypnow.co.uk 20th Sept 2011

O’Leary-Barrett M., Mackie C.J., Castellanos-Ryan N. et al.

Addressing the substance use promoting tendencies of the personality traits of London secondary school pupils at particular risk of substance misuse led to fewer drinking and, among the drinkers, fewer drinking heavily. The study showed that school staff could effectively conduct the focus group interventions.
Summary An alternative to prevention approaches applied to all children whatever their risk levels, the Preventure programme is a short intervention which targets youngsters who score highly on four personality dimensions which make different kinds of early-onset substance use and other risky behaviours particularly rewarding or hard to resist. As assessed by the Substance Use Risk Profile Scale personality questionnaire, these traits are:
Hopelessness A tendency to unhappiness, depression and feeling a failure, feelings relieved by intoxication;
Anxiety-sensitivity Fear of anxiety-related bodily sensations due to beliefs that such sensations will lead to catastrophic outcomes, for which substance use can represent a form of self-medication;
Impulsivity An inability to restrain seeking gratification in the presence of immediate rewards (such as the feelings available through substance use) despite longer term negative consequences; and
Sensation-seeking Desire for intense and novel experiences, which can be expressed as a desire to ‘get high’ through drugtaking or heavy drinking.

The Preventure intervention

The manualised Preventure intervention addresses these risk factors by drawing on psychoeducational approaches, motivational enhancement therapy, and cognitive-behavioural therapy, applied to real-life scenarios shared by high-risk young people in Britain. As implemented in the featured study, it occupied two 90-minute focus groups of on average six pupils led by two trained facilitators. Groups were formed of pupils who shared elevated scores on the same personality dimension, and the variant of the intervention applied to that group particularly targeted that dimension and the associated risks. In the first session participants were guided in a goal-setting exercise to enhance motivation to change behaviour, taught about the personality dimension and how it can predispose to problematic coping behaviours, and guided in breaking down personal experience according to the physical, cognitive, and behavioural components of an emotional response. All the exercises were specific to the personality risk factors identified in the children. The second session involved identifying and challenging personality-specific cognitive distortions which lead to problematic behaviours.
Preventure interventions have been found to prevent the onset and escalation of drug use over the following two years, but so far only as delivered by skilled research therapists. The featured study tested whether school staff, with moderate levels of training and expertise and competing responsibilities, could be trained to effectively deliver this unfamiliar interactive, small group intervention. Another issue was whether pupils would be open with adults who may hold disciplinary positions. On the other hand, it was possible that the teachers’ familiarity with their pupils would aid participation, and provide a platform for later addressing individual problems.
The study
Across nine randomly selected London boroughs, 21 randomly selected secondary schools were asked to join the study and randomly allocated to the Preventure intervention or to act as control schools which simply carried on (as all the schools had to) with the drug education components required by the national curriculum. Three schools could not be included in the featured analyses, leaving 18 schools and 2506 of the original 3021 year nine (ages 13–14) pupils. Of these pupils, 1159 or just under half scored as high risk on the Substance Use Risk Profile Scale; their responses were the basis for the featured report. 1008 could be followed up six months later; the probable responses of the remainder were estimated on the basis of earlier assessments and other data.
School staff running the Preventure intervention were trained in a three-day workshop followed by at least four hours of supervised practice and feedback on their performance while practising the full intervention with year 10 pupils from their schools. Though broader and longer-term outcomes are being assessed, the featured report focused on drinking six months post-intervention.

Main findings

Over 8 in 10 of the school staff members in the study completed training and supervision and qualified to facilitate the intervention. Each conducted on average six intervention sessions. Researchers observed at least one session by each facilitator. They judged that two thirds of the sessions had covered most of the core components of the intervention, and that two thirds also had been delivered in ways which embodied the required counselling skills of listening, enabling, involving the entire group, and being inquisitive and empathic. Facilitators themselves were all rated as at least satisfactory as cognitive therapists.

As expected, at the start of the study more of the high risk than the lower risk pupils (41% v. 32% ) had drunk alcohol in the past six months and more too had drunk heavily during that period (22% v. 12% ), defined as at least five drinks at one sitting for boys and four for girls. Six months later and compared to control schools, in schools allocated to Preventure the increase in the proportion of high risk pupils who were drinking was significantly less steep (rising from 43% to just 50% v. from 38% to 57%) chart. Narrowly missing statistical significance was a similar disparity in trends in the proportion drinking heavily across the entire population of high risk pupils; in intervention schools this rose from 22% to 25%, in control schools, from 21% to 28%.
A second set of analyses focused on the four in ten high risk pupils drinking at the start of the study. Among these drinkers, the proportion later drinking heavily actually fell in Preventure schools (from 52% to 48%) but rose in control schools (from 54% to 63%), another statistically significant difference. They were also consuming less alcohol overall, and were less likely to report drink-related problems.
These effects were comparable to those noted in previous trials of the intervention with specialist interventionists.

The authors’ conclusions

The was the first evaluation of a school-based personality-targeted intervention for substance misuse delivered by trained educational professionals. Compared with controls, the intervention was associated with significantly decreased drinking and drink-related problems six months later, and with fewer ‘binge’ drinkers among participants drinking at the start of the study – a particularly high risk group for future substance misuse. The potential health benefits of this delayed uptake of drinking are substantial: a one-year delay can decrease the risk for future alcohol-related problems by 10%.
These results replicate findings from personality-targeted intervention trials in the UK and Canada, but within an implementation model that has a higher likelihood of being adopted in the real world. The demonstration that trained and supervised school staff can achieve results comparable to specialist therapists means the intervention has the potential to become a sustainable school-based early prevention strategy with youth most at risk for developing future alcohol-related problems. However, it remains unclear whether ongoing expert supervision and/or performance and outcome feedback is required to maintain standards.
Among baseline drinkers, this trial and others have found that just from four to six young people need to be allocated to the intervention in order to later prevent one from drinking heavily – a ratio much more favourable than typically found for ‘universal’ prevention programmes which target all the young people in a population rather than just those at high risk, and which are typically of much longer duration.
The possibility that it was simply a group intervention which was effective rather than the particular content of that intervention is contradicted by studies which have compared the Preventure intervention to alternative group sessions, and by general findings that few interventions decrease substance misuse. From a similar UK trial which found reduced use of illicit drugs, it also seems unlikely that Preventure pupils in the featured study substituted these for alcohol.
In sum, the evidence appears to strongly support the use of this programme in schools, whether delivered by trained clinicians external to the school or trained school staff. However, implementations should include the expert training and supervision components unless and until it is shown that schools are able to deliver the interventions autonomously and effectively.
Relative to basic education without much if any intended prevention content, this and other studies have demonstrated substantial effects in delaying the onset of and retarding the growth of substance use. Few of the usual limitations on the generalisability of the findings to the normal run of schools apply to this study. Neither schools nor pupils were highly selected, all but a small proportion of sampled pupils were followed up, and the schools’ own staff conducted the intervention. As the authors comment, an impediment to widespread implementation may be the availability of expert trainers and supervisors. Another may be the willingness of schools to release four staff for three days training each followed by hours of supervision, and to let them spend many more hours addressing non-academic issues with a subset of high risk pupils. What may help convince them will be further results from the study if these demonstrate impacts not just on drinking but on mental health, other substance use, conduct, and academic achievement.
Among the findings is however the narrow failure to find a statistically significant impact on regular heavy or ‘binge’ drinking across all high risk pupils rather than just among those already drinking at the start of the study – a finding which seems to reflect the dilution of the results due to the inclusion of pupils unlikely to go on to drink heavily. This finding almost certainly also means no significant impact on regular heavy drinking across all the pupils in the school. Drinking as such at these ages is a concern, but in the British context, even more so is teenage binge drinking. That the intervention could not register even a short-term impact on this priority concern will lessen its appeal.
Its matching strategy above all distinguishes the featured intervention from other approaches. Plausibly, the developers argue that addressing each individual’s particular personality vulnerability to substance use should more effectively reduce or prevent that use than a more scatter-gun or generic approach. However, this remains to be convincingly demonstrated in studies which have offered essentially the same intervention, but not matched to the individual’s personality. It is possible that the advance made by the broad matching strategy embodied in the intervention’s manuals is not sufficiently great to improve on the ‘natural’ and possibly more fine-tune matching which occurs as a sensitive therapist or counsellor adapts their interpersonal style and the content of the intervention to the individual. Also at issue is the persistence of the effects past the first six months.
Other studies of the featured intervention
This study is one of the latest in a series investigating the same or similar interventions co-authored by the intervention’s developers. Given that allegiance to an intervention is associated with finding that it works, a fully independent demonstration by researchers with no personal investment in the intervention is desirable. Despite this, the body of work to date is methodologically sound, often convincing in its results and based on a plausible theory of how the intervention should work.
Among the British trials was another in London, but this time of a highly selected set of 347 schoolchildren counselled by a professional psychologist rather than school staff. As in the featured study, the intervention was associated with drinking reductions six months later, but these effects dissipated to insignificance over the next six months and remained so over the remainder of the two-year follow-up. This was in contrast to drink-related problems, experience of which increased over the first six months in the control group and remained higher than in the intervention group over the follow-up period.
Another similar study in London found that over the following six months the intervention delayed the expected increase in drinking among high risk pupils over the first six months of the follow-up, though again, by a year there was no significant difference in the drinking behaviour of pupils who had or had not been allocated to the intervention. The same trial found reduced uptake of cocaine and other drug use and a reduced frequency of drug use overall (but not cannabis in particular) over the two-year follow-up. In Canada too, the intervention was found to result in at least short-term (four months) drinking reductions in secondary school pupils.
As well as these trials among schoolchildren, earlier versions of the intervention have been trialled with adults and young adults. One trial focused on female undergraduates in Canada characterised by one of the personality traits investigated in the featured study – anxiety-sensitivity. Over the next 10 weeks, drink-related problems were relatively lower (but not quite to a statistically significant degree) among women allocated to an intervention targeted to their personality profiles compared to those allocated to a ‘placebo’ group intervention, but drinking itself was unaffected. Another study involved largely alcohol-dependent women in Canada aged 30 to 50 recruited via ads asking them to get in contact if they were concerned about their drinking or prescription drug use. A variant of the featured intervention was compared to a control intervention involving a motivational film on substance use problems and a supportive discussion with a therapist, a combination which it fairly consistently outperformed in reducing substance use. However, there were no statistically significant findings (though there were tendencies in this direction) indicating that the intervention bettered another intervention similar in every other way except that the content was not matched to the individual’s personality profile. These findings call in to question the matching strategy which above all distinguishes the featured intervention from other approaches.

Source.: www.findings.org.uk 16 August 2011
Journal of the American Academy of Child & Adolescent Psychiatry: 2010, 49(9), p. 954–963

Historian looks at resistance to the “NIDA paradigm.”

The history of addiction as a brain disease “looks a lot like the history of atoms or germs, insofar as these were older and controversial ideas for which scientific confirmation later became available,” writes historian David Courtwright, author of Forces of Habit: Drugs and the Making of the Modern World.

In a recent issue of the social science journal BioSocieties, Courtwright surveys the history of the disease paradigm of drug addiction, and, in doing so, brings into focus several key dilemmas related to what former National Institute on Drug Abuse (NIDA) director Alan Leshner once characterized as the “quintessential biobehavioral disorder.”

The scientific evidence available to us at present largely supports a statement like Leshner’s. Researchers have documented long-term changes in brain structure and function due to drug abuse, and neuroimaging technologies have resulted in maps of the abnormal neuronal activity addicts exhibit. Courtwright cites the discovery of the endogenous opioid system, the mapping of receptor pathways, and the growing understanding of the mesolimbic dopamine reward pathway as evidence of clinical confirmation of theories about addictive disease that has been floating around in one form or another for many years.

Why then, Courtwright asks, does the medical profession largely stay clear of issues having to do with our law enforcement-driven drug war? Why are clinical professionals not on the front lines of revolt over this issue? “If addiction was beyond the individual’s control, then criminal punishment was as inappropriate as jailing a schizophrenic who wandered into an emergency room,” the author writes.

The most obvious reason for this conundrum, says Courtwright, is that “the brain disease model has so far failed to yield much practical therapeutic value.” The disease paradigm has not greatly increased the amount of “actionable etiology” available to medical and public health practitioners. “Clinicians have acquired some drugs, such as Wellbutrin and Chantix for smokers, Campral for alcoholics or buprenorphine for heroin addicts, but no magic bullets.” Physicians and health workers are “stuck in therapeutic limbo,” Courtwright believes. “The drug-abuse field is characterized by, at best, incomplete and contested medicalization.”

Moreover, unlike the current situation in the case of, say, diabetes or schizophrenia, “at least four important groups continue to wrestle for control of the addiction field.” (Medical personnel, police, social scientists, and political officials.) Social scientists, in particular, are frequently skeptical about the NIDA disease paradigm “as part of a broader post-World War II pattern of resistance against biological explanations of behavior, genetic research and the neo-Darwinian renaissance.”

Social scientists and neuroscientists “still live in their own gated academic communities,” Courtwright alleges. “There is a lot more at stake in the brain disease debate than our understanding of addiction.”

However, these problems do not mean that valuable findings in one area–addictive disease theory–cannot produce innovations in other research fields as well. In fact, such spinoffs happen all the time. Courtwright points to advancements in our understanding of evolution: “Michael Kuhar has argued that, because the brain co-evolved with neurotransmitters, it can usually manage its internal chemistry quite well. But it did not co-evolve with drugs, understood as recently introduced and wholly exogenous super-neurotransmitters that can override the brain’s control mechanisms.”

The author also cites spinoffs in economic studies: “The permanent alteration of neurons and the development of addiction in some, but not all, users also helped explain the commercial and tax appeal of drugs, insofar as they were nondurable goods with relatively inflexible demand curves. Even non-addicted users tended to consume more over time, because of tolerance.”

In the end, it is just possible to contemplate some sort of fusion, or meeting of the minds, over the disease model. As Courtwright speculates, “it may turn out that the tension between the personality and brain disease models is more apparent than real.” He cites as evidence such connections as the fit between impulsive, thrill-seeking behavior and an associated paucity of dopamine D2 and D3 receptors in the midbrain region. The result? Such people “have less inhibition of dopamine, and experience more reward when stimulated by risky behavior.” A nice fit. And the number of nice fits between social science and brain science continues to accumulate.

“If the brain disease model ever yields a pharmacotherapy that curbs craving, or a vaccine that blocks drug euphoria, as some researchers hope,” Courtwright says, “we should expect the rapid medicalization of the field. Under those dramatically cost-effective circumstances, politicians and police would be more willing to surrender authority to physicians.”

Graphics Credit: http://alcoholanddrugabuse.org

SOURCE:HTTP://ADDICTION-DIRKH.BLOGSPOT.COM/2010/06/ WEDNESDAY, JUNE 23, 2010

UN-commissioned guidance from international experts on how to mount prevention programmes based on family skills training involving parents and children in a joint effort to improve family dynamics and child development. Engaging parents seems the major barrier.

Abstract
This review and guidance initiated by the UN Office on Drugs and Crime concerned the role of family skills training programmes in the prevention of substance use problems among children in families across the board (‘universal’), or families whose children are particularly at risk (‘selective’). Unless integrated with these types of interventions, the document did not include programmes aimed at individuals identified as at high risk or as already experiencing substance use problems (‘indicated’). A literature and website review identified 130 universal and selective programmes. Research articles and programme descriptions were solicited from the developers. Practitioners, managers, researchers and developers from these programmes throughout the world were invited to a technical consultation meeting. The guide was drafted on the basis of the discussions and the literature review. This account largely relies on its final chapter, which summarised the major points.
Families can act as powerful protective forces in healthy child development, in particular with regard to substance use. To bolster this process, universal and selective family skills training programmes generally aim at strengthening the protective factors in families, equipping parents with the skills to provide supportive parenting, supervision, monitoring and effective discipline, and giving entire families opportunities and skills to strengthen attachment between parents and children. These approaches are more intensive and differ from parent education, which typically limits itself to providing parents with information about substances and their effects and does not involve the children.
Such programmes have been extensively evaluated and found effective in preventing substance abuse and other risky behaviours – about three times more effective than life skills education programmes aimed only at children and young people, and with more long-lasting benefits. Conservative estimates indicate that for each pound spent, over the long term these programmes return a saving of nine pounds. They also form part of effective multi-component programmes which offer other interventions in other settings (such as schools, media and the community), and of tiered programmes which operate across several levels of prevention simultaneously according to the needs of the families (universal, selective and indicated).
Although the evidence is limited to few programmes in high-income countries, recommended principles for family skills training programmes can be identified. These include a solid theory of how the training will affect risk and protective factors based on research on factors related to substance abuse which can be addressed at the family level. Programmes should be matched to the target population, especially the age and developmental stage of the children and the level of risk or problems in the families. This makes accurate needs assessment vital. Programmes must be of sufficient intensity and duration to address the targeted outcomes. In general, universal programmes extend over four to eight sessions, selective programmes for higher risk families, 10 to 15. Sessions last about two to three hours and should be based on interactive techniques implemented in small groups of eight to 12 families. A typical and effective programme will provide parents with the skills and opportunities to strengthen positive family relationships, family supervision and monitoring, and improve the communication of family values and expectations.
Recruitment and retention of parents are significant barriers to the dissemination of such programmes. However, retention rates of over 80% can be achieved by addressing the practical (transportation, childcare) and psychological (fear of stigmatisation, feelings of hopelessness) barriers. Interventions are most effective if participants are ready for change, such as at major transition points like children starting school or a new school phase.
Often it most feasible and/or cost-effective to base a project on an evidence-based programme developed elsewhere for a similar target group, preferably one with the best prevention record. In this case, it is important to carefully and systematically adapt the programme to the cultural and socioeconomic needs of the target population. Such adaptations enhance recruitment and retention of families. However, during its initial use the programme should be implemented with only minimal local adaptations or changes. Feedback from participants and group facilitators on what worked or did not work so well can be used as the basis for further refinements. Experience with these and outcome evaluations should be used to assess whether a deeper adaptation is required.
As with other types of programmes, adequate training and ongoing support must be provided to carefully selected staff. Most evidence-based programmes require two to three days of training for 10 to 30 future group leaders. Training should give them the opportunity to practise their skills, but also discuss the theoretical foundations, evidence of effectiveness, and the values of the programme. Ongoing support by programme managers and supervisors (and, if possible and appropriate, from programme developers) is important, especially in the form of e-mail contacts and web-based networking of group facilitators across agencies. Site visits and debriefing sessions also enhance quality and fidelity of implementation, as well as the collection of monitoring data.
Programmes should include strong and systematic monitoring and evaluation components. This work contributes to the understanding of prevention strategies, indicating which programmes are effective, under which circumstances, and for which populations, and provides evidence of effectiveness which can be used to lobby policymakers and donors, potentially helping to sustain the programme.
There is no question that the family is a powerful influence on child development and on substance use and problems in particular, nor that interventions with families and parents can (see for example this demonstration from Sweden) help prevent substance use in various forms. What is questionable is whether the research, though sometimes promising, is sufficiently extensive and sound to warrant widespread implementation of these programmes. Searching for practical guidance, British reviewers found that research deficiencies mean that no clear choice could be made about what works best either for marginalised and vulnerable groups, or for families in general. The background notes focus on two of the best researched family skills interventions (the Strengthening Families Programme and the Family Check-Up) as a way of testing the adequacy of the evidence overall, and address the issue of engaging families of early adolescent children. For other relevant evidence run this search for pre-school and parenting interventions on the Findings site.
When in 2008 the US government analysed the costs and benefits of substance use prevention programmes, family skills training programmes were among those with the highest benefit to cost ratio, though they lagged behind some other school/community/family programmes, and also well behind some entirely different kinds of initiatives like enforcing laws on serving drunk customers in licensed premises. Estimates for the two relatively well researched family skills interventions focused on in the background notes rested on one or two studies, which in both cases provided a narrow and at best tentative basis for the calculations, casting doubt over the degree to which they can be relied on to guide prevention programme planning. Nevertheless, the same may be said of some of the other programmes included in the analysis. For the analysts, the major drawback of family training as a universal prevention modality was its higher cost relative to other types of initiatives, leading them to suggest that this approach be reserved for high risk schools, areas or families
A particular issue is whether by the time family skills training comes in to its own – from age six to 11, and in major studies not until the early years of secondary schooling – enough families can be involved to make these strategies a viable way of curbing youth substance use problems across the population as a whole. British experience so far suggests this is not the case, though high-risk families under pressure to attend and/or energetically and sensitively targeted can be engaged in and benefit from family skills training. As the featured review comments, one way cost and accessibility barriers are being addressed is through computerisation of such programmes so families can go though them at times convenient to them and in their own homes, a tactic trialled for example with some success among mothers and daughters in New Jersey.
Based on UK experience and the adequacy of the international evidence, family skills training programmes of the kind reviewed can be recommended for consideration for families who have come to attention because their children (age six upwards) are at risk of behavioural problems which may include risky substance use. Sensitive personal approaches from programme staff, perhaps preferably from the same communities, can recruit many to participate, stay in and benefit from the programmes. Universal application to all families seems at the moment to lack sufficient evidence (especially in the UK) to warrant the considerable investment required, a situation which may change if low-cost, accessible computer-based alternatives prove feasible, effective and capable of widespread implementation.

Source: K. Kumfer www.findings.org.uk 09 March 2010

In Sweden routine parent-school meetings incorporating parenting advice and encouraging commitment to take a strong stand against underage drinking had a remarkable impact on adolescent drunkenness – but would this simple, low-cost tactic work as well in the UK? 

Abstract
The Örebro Prevention Programme built on the fact that Swedish schools start each term with a parent information meeting. A survey of pupils in the final grade of compulsory schooling (roughly age 16) in the county of Örebro in central Sweden was used to select schools for the project in communities typified as inner cities, public housing areas, or small towns. Within each type of community, pairs of matched schools were selected, one of which carried on as normal, the other of which was assigned to test the prevention programme. None of the schools refused to participate in the study.
The programme was implemented across the final three years (grades seven to nine) of compulsory schooling when pupils were aged 13 to 16. Before the programme started, a survey of pupils in grade seven formed the baseline against which to assess impacts in this and the following two years. In each succeeding year the next higher grade was surveyed, meaning that largely the same pupils were followed up each year. In each year roughly 900 pupils evenly split between both sets of schools were asked to participate in the study.
Rather than through classroom lessons, the programme worked via the parents. At a seventh-grade parent information meeting, project staff gave a presentation describing the programme and advising parents to maintain a zero-tolerance stance towards youth drinking and to communicate clear rules to their children. This was reinforced by inviting attending parents to sign agreements about their positions on (among other issues) youth drinking; most did so. The agreement was mailed to all parents including those who had not been at the meeting. In each of the next two years project staff attended two further parent meetings to emphasise the key message of strict rules. Reports on the meetings were one of at least three mailings each term to parents. Mailings included letters (most co-signed by project workers and teachers) which stressed the importance of communicating family rules against alcohol and drug use and of promoting organised leisure activities.
 
The key question in the pupil surveys asked how often pupils had been drunk in the past four weeks. From virtually no times at age 13, in the control schools not participating in the programme the average rose to nearly once in four weeks at age 16  chart. From a similar starting point, it rose just half as much in programme schools, a medium to large programme impact as represented by the effect size metric. Also the proportion of pupils who had been drunk more than once during this period was twice as high (27% versus 13%) in non-programme schools.
At age 13 just under a fifth of the pupils said they had already been drunk. Among these high risk pupils the programme was just as, if not more, effective, halving the increase in the frequency of drunkenness; by age 16, without the programme these children were getting drunk on average twice a month compared to less than once a month in programme schools  chart. On all these measures for both full and high risk samples, there were statistically significant differences between programme and non-programme schools, and no indication that the programme was any less effective with boys than with girls or vice versa.
Pupils were also asked how often they had committed criminal or antisocial acts over the past year. Though the intervention had focused on drinking, here too there were statistically significant and medium to large programme benefits across the entire samples and among pupils in the top fifth of delinquency before the programme started. In respect both of drunkenness and delinquency, the there were no major differences between the three types of communities in the effectiveness of the programme.
One mechanism underlying these benefits was expected to be an extension of the parents’ strict anti-drinking norms in respect of their 13-year-old children to older ages. Based on the parents’ own accounts, the programme did significantly maintain these norms. However, there was no evidence from the children that involvement in adult-led organised group activities – another supposed means by which the programme would affect drinking – had in fact been enhanced by the intervention.
For the authors their study demonstrated that the parent programme had successfully influenced parental attitudes against underage drinking, resulting in (compared to most other prevention programmes) relatively large reductions three years later in drunkenness and delinquency across both boys and girls, among high risk pupils as well as the entire school year, and in different types of communities. It achieved these impacts despite being easily administered through existing parent–teacher meetings, costing very little to implement, and requiring just a two-day course for the people delivering the programme, who need not be specialist professionals. In the Swedish context they believed these attributes meant the programme could be implemented widely and largely within existing resources.
 In the Swedish context this was a convincing demonstration of the power of harnessing the parent involvement mechanisms and influence of the school to reinforce parental responsibility in respect of their children’s drinking. It is also a testimony to the potential power of unambiguous and simple messages congruent with the culture and to the strong influence exerted by parental attitudes and behaviours on when and then how young people drink. Whether it would work in drinking cultures like that of the UK is questionable. However, ease of implementation, low cost, the fact that no classroom time is involved, and the potential for substantial impacts, may be seen as making it worth a try, probably not as a standalone intervention, but to supplement whole school programmes, the promotion of activities which give young people a sense of achievement and belonging, and perhaps above all, cultural change which makes parents more willing and able to control drinking among underage children.
Though not clear in the featured report, it seems that parents at the initial meeting jointly develop an agreement concerning their stance on youth drinking, possibly adding group solidarity and continuing parent-to-parent reinforcement to the mix of influences leading to impacts  several times greater and more consistent than typical of alcohol prevention programmes applied universally to the entire youth population. This is the case even in respect of programmes recognised as effective and usually far more costly and difficult to implement. Confidence in the validity of these findings is weakened slightly by methodological issues; in particular, the failure to account for the grouping of children and parents within schools could have falsely magnified the apparent impacts. More in background notes.
Efforts to involve parents have generally been more elaborate but less successful than the one trialled in the featured study. A meta-analysis combining findings from randomised studies of parent-focused substance use prevention programmes found modest effects in the form of fewer adolescent children starting to drink and a lower frequency of drinking. This was particularly the case when whole schools were engaged in the intervention, offering an opportunity for pupils and parents who participated in the programme to influence those who did not. However, the findings were undermined by a general failure to account for families which were unable to be followed up.
A common practical problem is getting parents to participate in face-to-face substance use prevention programmes. Typically in Britain (see for example 1 2 3) and elsewhere in Europe, attendance is very low, especially among parents most in need of parenting support and with lenient attitudes to substance use. Generally in these studies the attempt was to encourage attendance at special add-on events. On this count the featured study’s strategy of incorporating prevention in to the school’s core parent involvement programme has a distinct advantage. The downside is that at these events schools have a limited time in which communicate with parents; educational and other social issues (such as knife-carrying, guns, bullying, illegal drugs, teenage pregnancy) are likely to be seen as higher priorities both by the school and by the parents. Other solutions tried in Australia and the USA involve mailings to parents from the school or parent-child homework assignments; more in background notes.
An obvious risk of encouraging parents to make their strictness about underage drinking known to their children, is that the children will respond by hiding their drinking, depriving parents of awareness and the opportunity to intervene. In Sweden but perhaps less so in Britain, voluntary self-disclosure is an important way parents learn about their children’s leisure-time activities. More in background notes.
As the authors acknowledged, the main question mark for readers outside Sweden will be the programme’s applicability to their cultures. Rather than having to create this, it merely had to extend the strict anti-underage drinking norms held by parents and communicated to their children when they were 13 years of age to later ages, when legal purchase was still many years away for their children. Such attitudes reflect national policy. For a European nation, Sweden has unusually restrictive alcohol laws, allowing legal purchase only at age 20 and confining the sale of anything other than low-content beverages to state-run stores, restrictions which make it clear that drinking is not mainstream and accepted.
As in Sweden, in Britain too parents seem influential in their children’s drinking, but as much in the direction of condoning as outright opposition. It would be a far bigger task to persuade the majority of British parents to harden their attitudes and keep them hardened as their child approaches the lower legal alcohol purchase age in the UK, where full-strength drinks are available in virtually every supermarket. In drinking cultures like Britain, advice originating from the school about the parent’s responsibility to communicate an unambiguous stance on drinking risks being seen as unwelcome meddling, especially by the heavy drinking parents whose children could most benefit from stronger parenting. See background notes for some relevant studies. A trial in the Netherlands of a Dutch version of the Örebro programme may be a better pointer to how it would perform in a drinking culture more like that of the UK. If so, it suggests that it would be a worthwhile addition to alcohol use prevention lessons, but not the standalone success it was in Sweden. More in background notes.
Attempts are however being made in Britain to harden parental attitudes to youth drinking. Aided perhaps by media coverage highlighting the risks of youth drinking, the relevant English national policy aims to develop a national consensus on young people and drinking. At the sharp end of the policy are court orders requiring parents whose children persistently drink in public to exercise greater control. Further down the scale are support for parents whose children are at risk of problems such as drinking, and the attempt to establish a partnership with parents based on a clear understanding of acceptable and unacceptable levels and patterns of youth drinking. So far however the message received by parents from other aspects of alcohol policy – alcohol’s mainstream position in society, and particularly the recent extension of opening hours – is that the government is not taking a stand to manage the issue of alcohol in society, undermining the credibility of calls for parents themselves to shoulder that responsibility.

Source: Koutakis N., Stattin H., Kerr M. Request reprint
Addiction: 2008, 103, p. 1629–1637.

The directors offer specific steps for planning and instigating the changes, provide real-life examples from diverse communities across the nation, and provide a road map for communities to adopt the six-step model all at once or one step at a time.

The report recommends screening each teen for drug and alcohol problems, assessing the severity of his/her drug and alcohol use, providing prompt access to a treatment plan coordinated by a service team; and connecting the teen with employers, mentors, and volunteer service projects.

The report describes how judges, probation officers, treatment specialists, families and community members can take steps right now to improve the future of these youth.

Upon completion of a brief survey, the full report is available as a PDF to download at no cost.

http://www.reclaimingfutures.org/?q=judicial_report_survey&reportname=ProjectDirectors

Publication Year: 2007

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COMMENTS by Mary Brett

Tackling Drugs To Build a Better Britain, 1998, had prevention as its priority, as did the previous, Tackling Drugs Together. So, in fact does the latest, Updated Drug Strategy, 2002. In David Blunkett’s foreward to this 2002 version, he lists prevention, education, harm minimization, treatment and effective policing as our most powerful tools. He ends with, “Future generations should never have to face the dangers and harm that drugs present to too many of our young people, their families and their communities today.”
The 2002 strategy talks about a stronger focus on education, prevention, enforcement and treatment to prevent and tackle problematic drug use, and aims to persuade all potential users, but particularly the young, not to use drugs. This, it says can be done by maintaining prohibition, which deters use, and by providing education and support.

I expected to find the word prevention or similar in 2.1, “Aim of drug education”.
I didn’t! I know that parents assume that drug education in schools is doing everything it can to strongly encourage their children to resist the use of all illegal drugs. Sadly many will find this is not the case. Why is this not the first aim of drug education? Nowhere in this section does it even hint that to resist drug use might be a good idea. Tobacco and alcohol ought to be mentioned at this point. The use of tobacco should be strongly discouraged, and information given about the sensible use and safe limits of alcohol.

Unfortunately, for the past fifteen years or so, the philosophy of harm reduction has been hi-jacked by most drug educators. Their view is, “kids will take drugs anyway, they must be told how to take them safely, and we must give them informed choices.” Apart from the fact that currently they do not receive true, accurate and reliable information about some of the drugs, especially cannabis (more on this later), there should be no choice – drugs are illegal. Do we let them choose to break the law by speeding or petty pilfering?

By no means do all kids use drugs. Maybe 30% to 40% do try them, but most give up after a puff or two. The vast majority, well over 80%, will never become regular or even occasional users. And as for safety, there is no guaranteed safe way to take any drug, including those on prescription.

Harm minimization, or the more usual term, harm reduction, has its proper place in dealing with known users, who already have drug problems, providing effective treatment and rehabilitation to break the cycle of dependence, while minimizing the harm that drugs can cause. Heroin users can be encouraged to “chase the dragon” (inhale the smoke), rather than inject, thus avoiding the blood-borne diseases.

I thought I might find the phrase “informed choice” somewhere, and I did, but I was more than surprised to find it in the section, 2.20, on Ofsted inspections for primary schools!
I would challenge anyone to convince me that children of seven to eleven have the necessary maturity and experience of life to be able to make an “informed choice”. Some of my sixth form boys lack this skill at seventeen! Recent research indicates that the brain does not fully develop till the mid-twenties, a lot later than previously thought.
At least in this section it does say, “helping them to develop and practice personal skills e.g. resistance skills”.

This government relies heavily, almost totally, on the charity Drugscope for its advice and information, and so, apparently does the DfES. It is an amalgamation of two previous charities, SCODA (Standing Conference on Drug Abuse), and ISDD (Institute for the Study of Drug Dependence). Literature from SCODA is quoted, The Right Choice, The Right Approaches and The Right Responses. On the covers we see a small logo with the words, “Good practice in drug education and prevention”, but inside we read, “ SCODA seeks to reduce the harmful effects of drug use through informed debate”. SCODA long ago abandoned any pretence at advocating primary prevention, they sometimes use the phrase “secondary prevention”, and say it is when children have already started to use. Anything after primary prevention, (stopping them from starting in the first place), is intervention and harm reduction. Even the DfEE Drug Prevention and Schools Circular, 4/95, also quoted, refers to “secondary prevention”. Pre-event, I would have thought, is quite clear in its meaning. Likewise the DfEE’s Protecting Young People, 1998, although emphasizing the aim of trying to encourage children to resist drug use, points drug educators in the direction of SCODA for resources.

 On page five of The Right Responses, 1999, it says, “Research indicates that drug education and prevention strategies are not able to prevent experimental use. There is growing evidence, however, of effective strategies which can reduce the misuse of drugs and the associated problems for young people, their families and their communities.” This is quite simply not true. The huge prevention campaign in the USA from 1979 to 1991 saw a 60% drop in drug use. Cannabis and cocaine use fell by fifty per cent. Twenty three million drug addicts fell to fourteen million. They then unfortunately, thinking the problem had been solved, took their eyes off the ball, and usage soared. A similar campaign is currently taking place there under the new drug tsar, John Walters, and once again drug use is falling. The Swedes have had excellent prevention programmes in place for many years, their level of drug use is around 2% to 3%. I have yet to find a harm reduction programme that matches these results.

I attended a session of the Home Affairs Select Committee (HASC) in March 2003, when Bob Ainsworth, the government spokesman on drugs was giving evidence. He talked constantly about harm reduction, and when questioned what he was doing about preventing young people from starting in the first place, he became hesitant and evasive. He said the government was doing lots of things, and when pressed, assured the MP, the Lib-Dem, Bob Russell, that the HASC was not going down the legalization route. Do politicians ever give straight answers to questions?

Children actually need rules and regulations, the only way they feel safe and secure is if they have boundaries to kick against. They have very little time for teachers who cannot control their classes. They often use their parents as an excuse when they want to get out of an activity with which they don’t feel comfortable. “Dad/Mum would kill me” is a phrase I often overhear. Ex-pupils who come back to see me are often the ones I have had to discipline most severely.
In The Right Choice, 1998, shock tactics are dismissed as lacking credibility and even glamourising drug use. Strangely enough it is claimed that “Just say no” falls into this category. In an English essay, set by one of my colleagues to year ten pupils, about what would put them off taking drugs, the commonest request was for accurate information on the harm they cause, but a surprising number said that shocking stories had a part to play. I never actually say, “Just say no” to my pupils, but I find that, if I give them the accurate, unexaggerated scientific facts about drugs and how they affect the body, add to that the adverse social, educational, emotional and family consequences of that way of life, spend some time discussing the various arguments surrounding drugs, and point out the employment potential of a drug user, most of them are deterred. I know, I get lots of feed-back. “Anyone would be mad to take drugs after that talk this morning”, was one of the comments overheard after my annual address to year twelve boys, reminding them of the dangers of cannabis. Earlier in their school career they have had sessions on self-esteem, peer-group pressure and other life skills, as well as being told of the dangers.

A few years ago, a former pupil came to see me. Having been a cannabis user, he had just managed to scrape into university with C and D grades. He was in his final year of a degree in pharmacology and wanted my help to write his dissertation on cannabis. I asked him what had stopped him. He looked surprised. “You did”, he said. “I could quote every word you ever said about cannabis, and all of it came true”. He also managed to stop some of his friends.

He got a first for his dissertation, spent a year as a technician with a friend of mine, a toxicologist, did an MSc in neurology, and is now researching brain diseases towards a PhD thesis.

“Harm minimization, on the other hand”, The Right Choice says, “reflects the reality that many young people use both legal and illegal substances ………… Those who advocate this approach acknowledge the importance of young drug users being aware of the risks associated with drug use, and aim to equip them with the knowledge and understanding that seeks to minimize them.” I reiterate, the vast majority of children do not use drugs.

Alcohol, of course is a different case entirely, section 2.5.1. Because it is a legal and widely used drug which can be consumed quite safely in moderation, harm reduction is perfectly acceptable. I would, however emphasise the need for a warning of the danger of overdose and death. Many children are surprised when told it can kill.

I have never understood why it is acceptable to be very tough and even authoritarian about tobacco and not about illegal drugs, section 2.5.2. “Discussions should make it clear that smoking is a minority habit”. So is regular drug taking. It is even more of a minority habit than smoking! “Opportunities to develop refusal skills are important”. They are even more important with illegal drugs but the guidance seems afraid to spell this out. “The question of smoking cessation should be addressed”. Of course it should!

Why does the emphasis shift when legal drugs are being discussed? I tell my pupils that they would be crazy to start smoking, but then I say the same thing about drugs. When you think about it, tobacco doesn’t cause the mental illnesses that cannabis does, nor does it stop you from concentrating and learning in class.

The word “prohibit” is used in this section in relation to members of staff. Prohibition is a dirty word with the pro-legalisation advocates. Just for the record, prohibition in the USA did work, at least in terms of health and economics. Cases of cirrhosis of the liver fell by one third, alcohol-related divorce, child neglect and juvenile delinquency in Massachusettes all dropped by fifty per cent. The overall murder rate surprisingly declined, and the incidence of psychosis caused by alcohol plummeted.

The problems arose because the use and purchase of alcohol were never outlawed, it was only the manufacture and supply. A huge loophole was its prescription for “medicinal purposes”. Also, at that time, an attempt was made to ban a legal substance that had been in use by most of the population for hundreds of years and which could be consumed without harm. Unlike cannabis: still only used regularly by a tiny minority, shunned by most people, and with no safe limits.

One of the most consistent characteristics of harm reduction advocates is the trivialization of the effects of cannabis. Drugscope has constantly stated that cannabis is not physically addictive. This is not true, and a quick look at the abundant research on this topic would show otherwise. Most drug education advice currently is at great pains to point out that “accurate and balanced facts” must be given, I wish they were! And they should not aim to “shock or horrify”. But drugs can and do do shocking and horrible things to people.

I personally know six people with young relatives who have developed cannabis psychosis and will probably never be truly well again. Psychiatrists will confirm that more and more hospital beds are now being occupied by young people suffering from psychosis or schizophrenia because of their cannabis use. Youngsters using tobacco, cannabis and alcohol have a twenty-six fold increase in their risk of suffering from depression. And Professor Robin Murray told a meeting of The Royal College of Psychiatrists in June 2003 that eighty per cent of the patients he assesses with their first psychotic episode have been using cannabis. He said, “The more cannabis that’s consumed, the more psychiatrists we are going to need”. A recent survey in New Zealand found that young male cannabis users were five times more likely to be violent than non-users. The risk for alcohol was only three times.

Cannabis smoke deposits three to four times as much tar in our airways than cigarette smoke, and causes rare head and neck cancers in young people, not seen in tobacco users till they reach the age of sixty and over. The British Lung Foundation has recently given a warning to young people. Lungs shot through with holes, and people of thirty waiting for transplants are all part of the sorry saga. The risk of a heart attack in middle aged users rises five-fold in the hour following the smoking of a joint.

Babies born to cannabis-using mothers are smaller and suffer from behaviour and learning problems as they grow up. Sperm counts are reduced, and cases of sterility and impotence have been reported. The immune system does not escape either, it is also badly impaired. THC interferes with the copying of DNA into new cells made in the body.

Vehicle accidents, as many as those caused by alcohol in some studies, have been documented in America, although nine to ten times as many people drink. Since the fat-soluble THC (tetrahydrocannabinol), the substance that gives the “high”, stays in the body for weeks, 50% is still there after a week, and 10% a month later, a person smoking a joint today should not be driving for at least twenty-four hours afterwards. This “clogging up” of the cell membranes by THC may even cause some brain cells to die. Brain cells are not replaced. Permanent brain damage is too high a price to pay.

Concentration, learning and memory are all adversely affected, causing pupils’ grades to fall. Often they miss out on university places. Even on one joint a month, a cannabis personality develops. Children become inflexible, fixed in their opinions and answers, can’t listen to reason, can’t plan their day or work out problems. Few children using cannabis even occasionally will achieve their full potential.

And cannabis can act as a gateway drug. Numerous studies in the USA, New Zealand, and the latest, using twins from Australia, confirm the trend. Of course not all of them will progress to more dangerous drugs, but almost 100% of heroin users started on cannabis.

The cannabis of today is at least ten times stronger than it was in the sixties, and skunk and nederweed, varieties specially bred in Holland, have THC contents of anything from 9% to 27%, up from the 0.5% of forty years ago. Today’s cannabis is a totally different drug.

Is all of this not shocking? The Drugscope website contains very few of these facts. There is no mention of effects on the heart, the immune system, reproductive system, long-term storage or increased strength of THC. Conclusive proof is demanded. We still have no conclusive proof that cigarettes cause lung cancer, but because of animal experiments and statistical evidence, we accept the link. Why is it different with cannabis? One of the booklets about cannabis, distributed by Drugscope, shows a picture of two young chaps in a field of cannabis plants, one of them is wearing a cap with the logo, “Have fun, take care”. What sort of message does that send to our impressionable offspring?

Unless Drugscope and other similar charities get their acts together and up-date their information to give our youngsters what they deserve, advanced warning of the true hazards of this insidious drug, then our children are being betrayed. No wonder there is a disclaimer about information on their website. How can our children “ make sensible informed choices” when they are not properly informed? They should be encouraged to access scientific papers and books to get the real picture.

This guidance is full of statements like, “accurate information”, section 2.1, “real dangers”, section 2.2, and “credible information which does not exaggerate but clearly explains the dangers of drugs ….”  If only this were true!
Drugscope does not want people in possession of small quantities of drugs to be arrested – any drugs! They enthusiastically endorsed David Blunkett’s proposal to down-grade cannabis from class B to C. An absolute disaster waiting to happen! The number of young boys using cannabis has jumped 50% from 19% to 29% since his ill-advised announcement. In May 2003, on radio four, Roger Howard, chief executive of Drugscope, advocated the re-classification of LSD and Ecstasy as well as cannabis.

In the Department of Health’s “The Dangerousness of drugs”, the information on cannabis is much better than that of Drugscope, if only teachers have time to access it. However it falls short in some respects e.g. the fact that THC stays so long in the body is not spelled out and no mention is made of the increased strength today. In the driving section, no warning is given of the long-lasting impairment of skills, and the dependence potential is played down. The possibility of people becoming violent is omitted, and in spite of the many studies on children born to cannabis-using mothers, the results are questioned, even those that have consistently found the weight of these babies to be reduced.

Turning to the reclassification proposal, section 2.5.3, the assertion that cannabis is less harmful than drugs like amphetamines is debatable. Amphetamines, unlike cannabis, disappear from the body within forty-eight hours, so don’t have the long-term effects on concentration, learning, memory and therefore academic performance. Nor do they cause cancers since smoking isn’t involved. The immune system is not impaired. Both drugs are associated with heart attacks, confusion, depression, aggression, psychosis and paranoia, but I have never read that amphetamines can trigger schizophrenia. Nor have I seen evidence of them adversely affecting the foetus.

Children want lessons from people who know what they are talking about, section 2.2, I could not agree more. But many teachers in charge of drug education are not biologists. A good number are RE staff. When they receive drugs literature in school, they must naturally assume it is reliable and trustworthy. Teachers are busy people and will use worksheets if they are provided. One of the worst I have seen is entitled “Absolutely Spliffing”.  Messages again! Another has a table to be filled in, signed by S.P.Liff!

The various games, debates and activities suggested in the guidance, section 2.9.3, are useless without the true facts being known. I have never been a great advocate of playing games to get over the point about drugs. One book, giving guidance on drug education, suggests using syringes, foil, matches, cigarette papers and drink bottles. This leaves me feeling distinctly uneasy. Debates are excellent vehicles for an exchange of views, but when the sources of information recommended to them are heavily biased, then the whole exercise is badly flawed.

Connexions, the organization now responsible for distributing information to schools on various subjects, including drugs, is obviously mentioned. I recently had cause to complain strongly about some of the drug leaflets they sent out. They were written by the “Clued-Up Posse”, a group of kids from Fife. Not surprisingly they had very little information in them, were written in “trendy” language and had masses of advice on harm reduction. My sixth form thought they were useless, patronizing, and positively encouraged drug use. They pointed out to me that the cannabis one was a replica of a Rizla packet. Again, what message does that send out? In my view this is totally irresponsible and one MP has tabled a written question for me. I await the reply.

The Department of Health is not above blame either. In a recent poster sent to school offering a list of resources, the charity Lifeline was given. When I gave oral evidence to the HASC on cannabis in January 2002, I showed them some of Lifeline’s publications. “How a joint is rolled”, a set of diagrams in their cannabis leaflet, “Don’t get caught in the first place”, advice to children on how to survive their parents finding out they are using drugs, and a hint not to use an old LP record to place their cocaine on as it gets wasted in the grooves, are just some of the “gems” of advice from this charity. Their “street-wise” literature is full of sexually explicit cartoons and four-letter words.

To give them their due, the committee was collectively shocked, they have launched an investigation, particularly into the funding, which comes mostly from local health authorities and central government. The reply to my MPs question as to whether they would withdraw the poster was that they had no plans to withdraw it and would have no reason to do so.

QCA literature is also recommended. I recently wrote a criticism of their 2003 guidelines on tobacco, drug and alcohol education. My comments were very similar to these ones.

National Helplines, section 2.23, do not always help! I have lost count of the number of  parents who have contacted me because the advice is, “Don’t worry, it’s only cannabis” These desperate people know full well what is happening to their children and they are frantically looking for information about the drug that fits in with their experiences. Most recently, a despairing mother rang me. She had been trying to get someone to listen for six years, and I was the first person who had actually related to her problems.

On November 28th, 2002, 14 of us gave papers on cannabis in The Moses Room in The House of Lords. The Conference, entitled Cannabis – A Cause for Concern? was chaired by Lord David Alton. Seven other people gave testimonies, among them a young girl, a non-user. She said, “—-you adults have to say that you care, that you feel strongly about what we do – don’t leave it as a choice. If you don’t want us to do drugs then say so – and say why. You don’t ask us to choose whether to steal, or to attack people, so why leave us to choose about drugs”?  It was like a breath of fresh air.

Prevention has always been better than cure and always will be. We have massive prevention campaigns for drink-driving, breast cancer, heart disease and so on. Why on earth can we not see that preventing drug use must be our greatest priority.

Nagged once more by her computer, leading journalist Melanie Phillips checked her email.  The inbox was full again; an unprecedented influx, and all caused by one Sunday Times column that week (Phillips, January 2000).  The theme was ‘Britain is quietly turning into a drug culture’.

Feedback in the following Sunday’s letters page was numerically balanced, two for and two against.  In contrast Melanie’s inbox had at first been flooded with supportive mail from professional and lay sources alike, but as the week ran on the antagonism quotient rose, with one peculiar characteristic – an uncanny similarity in the phrasing in many letters ………Phillips took a broad view of the scene – unavoidable if one is to have any chance of reaching a balanced measure of this convoluted subject.  Parents, police, politicians, pushers, promoters of law relaxation – all these and more were addressed.  But of all the sectors to come under the author’s microscope, the one which provoked the most anguished outcry in the subsequent Letters page was, as might have been expected, education.

Phillips voiced the concerns of many professional observers of the drug education when she addressed the

‘…false claim that there is such a thing as responsible and safe drug-taking.  This belief has taken firm hold in Britain and is behind the shift that has taken place from prevention to ‘‘harm reduction’’. Clearly, there’s a place for harm reduction in treating individual addicts; but the idea that drug-taking can be made safe is utterly wrong.  There’s no such thing as a harm-free drug.  Yet drug ‘education’ is all about telling the young how to take drugs ‘safely’. Such classroom materials normalise and encourage drug use, while providing minimal information on harm …’

In response, one letter (Towe, 2000) spoke of how drug education ‘… far from telling them ‘how to take drugs safely’ … focuses on encouraging them to make responsible choices’  The letter went on to deny having ‘… given up the struggle and (thus) … being content to ‘normalise’ drug use among young people …’; an assertion which the writer found ‘… deeply demoralising to the many conscientious teachers and youth workers who deal with this issue on a daily basis.  (emphases added).

This exchange goes to the heart of the conflict around drug education, and thence the wider subject of drug prevention, not just in Britain but in several countries.  There is, in truth, a war about the ‘war on drugs’ – how should it be conducted and with what goals.  In this context the letter reacting to Melanie Phillips article is more revealing than perhaps the writer intended.

The Drug Education Forum, of which the letter writer is the current Chair, started out with a mission statement mirroring the National Drug Strategy, in seeking to develop young people’s skills and attitudes so that they ‘… can make informed decisions to resist drug misuse …’ (emphasis added).  But by some two years later – in mid 1997 – the mission statement was modified, by deleting the last four words (as emphasised above).

To the casual observer, or even the less than awake worker in the field, this might seem an innocuous change.  Far from it; this change meant that drug education should now serve any decision – to avoid drugs, or to use them.  Indeed, as the Forum has subsequently said, they would expect education to support ‘… the values inherent in informed choices …’ including ‘…the choice to use drugs …’ by giving ‘… information about ways they can do this as safely as possible …’ (emphases added).  Two years before this change in the Forum’s stance The Times (1995) ran an Editorial Comment which accurately anticipated this kind of move:

‘… One difficulty (in schools) has been that the message has been compromised by relativism and moral confusion: teachers, reflecting the wider debate, have linked drugs with alcohol, and suggested that both are a matter of personal choice.  Many of the drugs advisors resist the idea that they should label any activity as morally wrong even if it involves breaking the law.’

So, who speaks the truth?  Is education firmly set on preventing drug use, or is it in the thrall of libertarian ideologues?  One might first have to identify what truth is. One suggestion; cynical, perhaps, but in itself having the ring of truth, is that

‘Truth may be defined as that which is ultimately satisfying to believe’.

Both parties would, by this measure, claim to be guardians of  ‘the truth’;  that they alone hold the moral high ground.  Hence the current internecine conflict in at least the advisory levels of the education field.  Meanwhile down at the coal-face, Towe’s assertion that teachers and youth workers all ‘deal with this issue on a daily basis’ is a world away from the experience of this writer.  Many do not ‘deal’, nor even wish to deal with this ‘hot potato’ at all.  Youth workers may well encounter it more often, but their circle of youth contacts is small in comparison with the total school population, and there is anecdotal evidence to suggest that youth club patrons have a disproportionately higher prevalence of drug misuse amongst their numbers.

There is no doubt this is a complex and emotive subject; the conflict around drug education in part reflects this, but in part drug education’s philosophical sectarianism adds to the very problem it was conceived to address (Stoker, 1999).  It is a key negative factor in the performance of prevention in Britain (and some other countries).  It is possible to observe certain patterns in this which hint at the reasons for the conflict.  Some are ‘self – based’, such as turf protection, fears for job security, and innate hostility to ‘outsiders’; the current situation with the DARE (UK) programme – which utilises purpose-trained police officers in primary schools – illustrates this point. (Stoker, A: 1999)  Life Education Centres (Kaplin, 1997), which uses ‘Educators’ generates somewhat less hostility in this respect, insofar as Educators are perceived as being ‘of the teaching tribe’, though there can still be concern at the arrival on site of skilled outsiders, and this can sometimes foster criticism.  But a driving force which arguably exceeds all these other motivations is educational philosophy, capable of producing conflict of a deep and damaging nature.  The struggle between educational philosophies and their interrelation with societal cultures cannot be fully explored in a brief paper such as this; it would certainly consume several doctoral theses on its own.  But one can attempt a summary…

Looking at a wider stage than the immediate confines of drug misusing behaviour, external factors relevant to moral development (or decline) have played a major part in affecting what happens within as well as outside the school gates.   There has, in general terms, been an emancipation and empowerment of the young, plus a great increase in their disposable income, at the same time as a disempowerment of teachers and other authority figures.   Parents have likewise seen their powers eroded and, when it comes to subjects such as sex and drugs, they perceive themselves to be inhibited or – in extremis – disqualified from comment or control by ignorance of the details, the jargon and their (arguable) lack of credible experience in today’s scene.   At the same time factors such as the emergence of the ‘Me Society’ (not wholly Thatcher’s fault!), and the ‘If It Feels Good, Do It’ or ‘Do Your Own Thing’ mantras, combine with what social psychologists call ‘Rising Expectations in Post-Industrial Society’ and the cult of ‘Personal Rights’ – including the ‘Right to Be Happy’.   Factors such as the above may also, in some respects, be applied to adults, and may be viewed as contributing to the breakdown of the nuclear family:  the rise of materialism; fight for employment survival, and preoccupation with the adult’s problems while being too busy to recognise danger signs in their offspring.  Also evident is a search for rapid, as distinct from delayed gratification.   Religion as a moderating influence has subsided (the usual consequence when the foundations of something are undermined).

Some initiatives in social education such as ‘Self-Esteem Building’ started from morally defensible motives, but strayed later.  One could even defend the more sensible examples of Political Correctness under this heading, and the core value of Harm Reduction as traditionally practised (ie. engaging with people known to be using drugs, to mitigate the effects of their use whilst working towards abstinence) is likewise worthy of support.  Unfortunately the outcome from this mixture is not always what was expected.  As one American sociologist ruefully remarked to this writer:

‘When you’re up to your rear end in alligators it’s kinda hard to remember you started out by wanting to drain the swamp’.

In the context of youth and drugs the outcome may be characterised and described in one of two ways:

either (1):   Young people want quick pleasure;  they want their ‘rising expectations fulfilled now, so that their ‘right to be happy’ is exercised.  Drug misuse seems to be both celebrated by  media and youth icons as well as effectively condoned by harm reduction information and only limply constrained moral guidance (nowhere near as important as one’s self-esteem).  Drugs are also more available, cheaper in real terms  and a lower proportion of one’s disposable income.   Thus drug misuse appears to become a viable option.  Society says ‘It’s your choice, as long as its an informed choice’.   Teachers are awash with curriculum and management demands, and parents have retired to the margins;  hence the ‘informing’ of choice is effectively left to a small number of education advisers, youth workers and the like.  If they are disciples of a Values Clarification approach (see below) or if they see accepting youth behaviour, rather than setting any boundaries, as the price for credibility and acceptance by youth, then the stage is set for a disaster.

or (2):       We’re up to our rear end in alligators.
 

How did we get here?

It was in the 1960’s, both in the UK and the USA, that a sea change in educational approaches fully took hold; morals-based education gave way to individual rights. (Naylor, 1999).  Whilst there is undoubtedly merit in, say, relinquishing authoritarianism in favour of a valid degree of democracy in the classroom, several commentators are now remarking on what became a sustained torrent, sweeping away the foundations of practice rather than stopping with the removal of some redundant or otherwise lesser-valued superstructures.  (Education Issues, 1999).  So it was that apparently disparate subjects such as reading, mathematics, history, geography, and religious education fell victim to the excesses of an overheated individual–rights approach in which some pupils could even decide whether to participate in classes or not.  In the case of the last of these (religious education) there was an even more profound retreat from tradition. It was almost axiomatic that ‘lifestyle’ subjects such as sex education, drugs education, and umbrella subjects like PSE/PSHE – Personal, Social, Health Education – would be at the forefront of the flow.

Francis Fukuyama is one who has taken the measure of this; in his book ‘The Great Disruption’ he advances several possible reasons for the changes in educational process.  (Fukuyama, 1999).  Whilst his hypotheses are open to debate, especially since they curiously omit any reference to a moral dimension, the changes in social behaviour in the last three decades are a matter of sobering fact.  Educational analyst, former Schools Council (now QCA) member and head teacher Fred Naylor has correlated US government statistical publications (Naylor, 1999) to produce a salutary summary, showing juvenile crime up 300%, rampant use of illegal drugs, abortions up 800%, illegitimacy up 450%, and STD’s up by more than 200% . Accepted indicators of family life showed it to be moribund.
 

Added Value?

A further major player, not widely recognised is the UK but certainly influential on pedagogy here is the approach known as Values Clarification, identified by some commentators as part of the ‘Outcome-Based Education’ (OBE) school of thought. (Citizen’s Commission on Human Rights, 1999).  This originated in Wisconsin, USA in the 1970s and eminent co – authors of the approach included the psychotherapy guru Carl Rogers, Professor Sidney Simon and psychologist William Coulson.  Like many approaches which go awry, Values Clarification started from a laudable concept i.e. that pupils should be facilitated to discover , and thus reach consensus on ‘values which are beneficial to society’.  But within a short time the concept was diverted (some would say subverted) to one in which pupils crystallised values which were beneficial to them as individuals; (Markwood, 1999) external constraints from society, authorities, parents etc, were to be viewed as obstacles to the individuals’ ‘self-actualisation’ – as Abraham Maslow, another contemporary of Rogers, terms it. (Maslow, 1954)

Naylor comments on this in his 1998 consultation document to Britain’s Social Exclusion Unit. (Naylor, 1998)  His paper is targeted on teen pregnancy but makes strong reference to drug misuse as part of the ‘joined-up problem’ which ‘joined-up government’ needs to address.  Naylor quotes Yankelovich et al. who have demonstrated major correlation between ‘smoking habits, cannabis use, sexually precocious behaviour and the relationship between younger women and their parents’. (Yankelovich, 1997)  Dryfoos (1993) is also cited in endorsing these links between what he called ‘the new morbidities of youth … ‘resulting from drugs, sex, violence, depression and stress’ .

The diverted/subverted Values Clarification approach remains a powerful influence in its own right; not just on young people’s behaviour but also on teachers, and thus their approach – in class, and pastorally.  Looking back over the past three decades there seems little doubt as to the influence of this and related philosophies on the agendae espoused by teacher training colleges and other formative entities in the field.

It would seem that the notion of individual freedom had somehow become entwined with the grossly inaccurate view of drug misuse as a personal matter, affecting no one else.  The colossal falsity of this view is indelibly impressed upon this author, after more than 15 years of working with drug misusers, their families and societal/justice/health systems.  This individualistic ‘personal choice’ model was certainly given voice in the Values Clarification model, which espoused

‘…The revolutionary notion that children should be left to create their own autonomous world, and adults are being anti-democratic in trying to pass their values to their children’. (Naylor, 1999).

One of the original architects of Values Clarification was the influential American psychologist William Coulson, a close associate of Carl Rogers and co-practitioner of Roger’s ‘non-directive therapy’, in which people with problems are not furnished with (external) answers but instead are assisted to discover the answer within themselves.  This has become a cornerstone of UK counselling, and for problem–solving it does at least have the rationale that a solution arrived at by the client may have more chance of ‘sticking’ than one externally delivered.  But this has to do with ‘problem people’.

Another definition for Rogers’ approach is ‘client–centered’; the similarity between this term and ‘pupil – centred’ is no accident.  It identifies the pragmatic transfer of problem-solving therapy into general education.  For Coulson this at first seemed (Coulson, 1994) a sensible progression; in his own words “We had the idea that if it was good for neurotics, it would be good for normals”.  But as time passed and Values Clarification transmogrified towards its present form, he became more and more disturbed by what he saw.  An early warning sign came when Rogers and Coulson tried floating the programme with what they deemed as ‘ordinary’ people in Rogers’ home/university state of Wisconsin.  Coulson observed that ‘the normal people of Wisconsin proved their normality by opting out, on being told what the concept was… ‘so’ said Coulson ‘we went to California.’  That did it.

Some years later, as the (Rogerian) Values Clarification practice spread to Australia, an Education Conference (Bowen, 1990) in Victoria heard an analysis of what the speaker, Jim Bowen, described as ‘…the causes of the crisis in Australian education’  Bowen, a barrister and president of the Australian Family Association in his state, quoted Professor Sidney Simon, Values Clarification co-author as saying:

“The school must not be allowed to continue fostering the immorality of morality.  An entirely different set of values must be nourished”.

Bowen goes on to describe how Values Clarification had been seen in action, in the schools in Victoria State:

‘Application of values clarification techniques in the classroom requires children to choose a value, affirm it publicly, and be prepared to defend it under pressure from the teacher and classmates.  Children are subjected to searching questions about personal and family beliefs, attitudes and behaviour…In a context resembling group therapy, powerful psychological tools, such as sensitivity training are employed to produce changes in children’s attitudes and behaviour.  In role playing games, children are subjected to mental stress through emotional involvement.  Doubts concerning previously held values and loyalties are implanted while children are psychologically vulnerable, leaving them open to implantation of other values.’

In (Gestalt – based) educational practices in Switzerland, similar approaches were encountered. (Citizens Commission on Human Rights, 1999)  Amongst other expressed objectives was the ‘need’ to understand that:

‘Morals are regarded as obstacles which hinder the development of ‘my authentic self’ and the teacher has no right to impose his sense of values about what is right or wrong’.

Regrets, I have a few

Some years into the Values Clarification era there were increasing signs of disquiet, even amongst the prime movers.  William Coulson became one of the fiercest critics, and another eminent professional, Abraham Maslow, joined in disparaging the process. Maslow warned early of some of the risks he saw in Values Clarification. (Coulson, 1994)  According to Coulson, “Maslow …believed in evil, and we didn’t.”  (Astonishing, considering Coulson’s background as a practising Catholic, graduated from Notre Dame), ‘Maslow said there was danger in our thinking and acting as if there were no paranoids or psychopaths or SOBs in the world to mess things up… We created a miniature utopian society, the Encounter Group.  As long as Rogers and those who feared Rogers’ judgement were present it was okay …. He kept people in line; he was a moral force’.

But the self-destruct ‘outcome’ of the approach was beginning to worry even Rogers.  In  a 1976 tape interview (Coulson, 1994) with Coulson, Rogers referred to it as “this damned thing…” and expressed concern that he didn’t “… have any idea what’s going to happen next … did I start something that is in some fundamental way mistaken, and will lead us off into paths that we will regret?”

Coulson tried to construct a rationale for  this by referring back to his own religious antecedents, and looking for some related sense of  religiosity in his colleagues and himself..  But  Rogers  claimed to be ‘too religious to have a religion ….. I don’t follow a creed, I make my own.’ Says Coulson: ‘Rogerians have no tribe except for everybody; and everybody is too large to give any sense of definition, of limit”.

This is not to say that religious faith is the whole of the solution (at any rate, not as perceived by this author).  But for many people (including this author) their religiosity guides them with a moral structure and, on a more general level, non–sectarian authorities such as the World Health Organisation still explicitly identify spiritual health as one key element of total health.

‘Development’ of ‘modern values’ continues today; the 1999 pre-launch release of a new British publication, the Journal of Values Education, predicts that a ‘values education’ approach would have young people discuss such questions as:

‘Are drugs really bad for you ?’ and
‘If adults drink alcohol why shouldn’t I take ecstasy ?’

These may be legitimate secondary school senior form debating topics, but caution coupled with a keen eye for ‘heffalump traps’ is a prudent necessity; pupil age and teacher competency are vital, if this kind of exploration is not to go badly off-track.
 

Reasons to be cheerful

A major marker on values was put down by the Government in May 1999 when, in response to strong criticisms they withdrew a draft Guidance on PSHE (Personal, Social and Health Education) which made no mention of marriage, let alone advocating marriage as a socially constructive condition.  In the resulting rethink Minister Paul Boateng voiced the policy of his senior Minister David Blunkett when he went on public record (Boateng, 1999) as saying:

‘We can’t, and we’re not going to, have a value-free curriculum’

The remark was welcomed by other parties and by (some) education specialists.  Opposition MP David Willetts expressed the hope that there would now be abandonment of ‘the claim that you can teach about these things without any moral framework’.  The working group responsible for this aberrant PSHE Guidance, under the chairmanship of Estelle Morris (Education) and Tessa Jowell (Health), were not the first to ‘overlook’ marriage as a recommended option.  Some three years earlier the then education Secretary,  Gillian Shepherd,  found  it  necessary  to  amend a draft ‘statement of values’ which had initially said nothing about marriage.  Calls for a ‘stronger statement of family values’ led to the finalised statement committing to ‘support marriage as the traditional form of family unit’.

It should not be assumed that such statements of family values axiomatically exclude other lifestyles; what is being seen here is reaffirmation of societal core values which are resurfacing after a period of calculated erosion, largely inspired by the proponents of alternative lifestyles (and often, understandably, arising from these alternatives having had historical situations of social prejudice and disadvantage).  The pendulum is likely to swing back and forth in this respect for the foreseeable future, the possibility of a stasis acceptable to all being remote with such a volatile subject.  It ought, however, to be possible to gradually (or, dare one say, ‘progressively’) dampen the amplitude of variation about the mean, given sufficient will and wisdom.
 

Hope rather than dope?

In this ‘PC’ age we seem to constantly – at least figuratively – tie our shoelaces together before entering the race for the hearts and minds of our young.   To ‘moralise’ is now deemed to mean being superior;  you can be a ‘patron’ (protector, advocate) as long as you don’t ‘patronise’;  having ‘values’ is code for saying you are old-fashioned …. Victorian, even;  ‘family’ is passé, and there are no children, only young adults.  When it comes to drugs, the period of misusing them is a ‘career’, and their use is typified as ‘social’ or ‘recreational’.   If nothing else, a return to some sort of balance will require a complete overhaul of the semantics surrounding this issue.

The implications of all this for schools, and – not least – teaching staff, are stark.  But the situation is far from irreversible;  it became worse by small degrees, and resolution is likely to proceed at no faster pace – not least because the present incumbents, the so-called ‘progressives’’ will neither change philosophy nor move over without significant input of energy and solid argument by others.  What is more likely is that things will get worse before they get better; meanwhile, at the ‘chalk-face’, hard-pressed teaching staff will continue to strive for the best for their pupils.

Vying for scarce funds escalates healthy competition into unhealthy conflict, thus we find education workers denigrating each other.  It does seem that it is in the arena of educational philosophy that  the bloodiest battles are fought.  In this arena the middle ground is only entered when heavily armoured, and any concession from the other side is seen as a weak point begging for a fatal thrust.  Peacemaking is not always easy; say too little and you are arrogant – say too much and you are patronising.  Perhaps it would help, when helping to bring organisations closer, to remember that:

‘The reason we often don’t communicate is that we build
towers instead of bridges’.

Constructive criticism of this state of affairs should strive to avoid not only ‘educationist Luddism’ but also the far reaches of moral absolutism and repression – however, a clear moral stand cannot be ducked.  One could start by conceding that many involved in the so-called ‘progressive’ movement went there for the best of reasons.  It is also fair to say that some educational changes in this context replaced poor or negative practices.  For example, few of us would wish to return to an autocratic or authoritarian classroom constrained to unremitting didactic presentation.  (This author certainly would not).  But there is a sensible middle ground, in which the learning environment really is focused on useful learning whilst at the same time it encourages exploration and consensus, achieved by an appropriate mix of the didactic with the interactive.  And, moreover, a clear definition of where society places its boundaries, and why, i.e. the values on which these boundaries are based.  It is a matter of some surprise (or should be) that drug education ‘progressives’ should advocate the total absence of values – the spuriously–named ‘value–free learning environment’ – when considering drug misuse.  These same individuals see no problem in defining theft or violence (or even driving on the correct side of the road) as boundaries not to be transgressed, in order to uphold society’s values (and health).  The argument is therefore not about the need for boundaries per se, but rather about where they should be placed.  History may yet tell us why the ‘progressive’ educationists believe that drug misuse is a special case for which values and boundaries i.e. morals, are not relevant.

Whilst the worst excesses of ‘OBE’ and Values Clarification are to be avoided, there can be merit in an age-appropriate discussion of why society has values and boundaries; why they are set where they are, and therefore why they should be followed.  This could be related to simple school ‘rules’, as an example having some immediacy for pupils.
 

A Constructive Plan

Learning from international research and practice in drug prevention and related issues, sufficient lessons can be learnt to sketch the framework of a more effective approach. A school’s drug policy should not be confined to intervening when problems arise;  it should define goals with clear values and boundaries, and say how it will achieve these goals (i.e. prevention) – only then should it turn to responding to individual aberrations, responses which focus less on punishment and more on return to acceptable behaviour.   Learning how to make ‘Informed Choices’ can be facilitated but should not extend to those behaviours for which ‘choice’ is inappropriate e.g. lawbreaking, including drug misuse.   The schools’s ethos should encompass responsibility to Society, not just to Self; the pursuit of Liberty but not of Licence; exercise of Rights but with the accompanying Responsibilities, and an unequivocal understanding of the consequences of breaching the school’s behaviour code … this way, the pupil is not so much being ‘punished’ as receiving the consequence they have ‘earnt’.

This brief paper has attempted to indicate explicitly how and why the present unhealthy and counter-productive situation around drug prevention and education has arisen. It is to be hoped that papers like this will encourage some new flexibility into the dialogue. There are no illusions as to this process being quick; nor will it be without pain, especially that ensuing from grasping that fearsome nettle known as ‘Morals’.
 
 

References:

Bowen, J. 1990 ‘Why classrooms have become a battleground’.  Australian News Weekly.  3 March 1990.

Boateng, P. (1999) ‘Blunkett climbdown on morality lessons’.  Daily Mail. (London) 15 May 1999.

Citizens Commission on Human Rights (1999).  Psychiatry’s and Psychology’s Eradication of Right and Wrong. Contact Lord/Lady McNair Box 28008, London, SE27 0WD.

Coulson, W.  (1994).  ‘We overcame their traditions, we overcame their faith’.  The Latin Mass.  1331 Red Cedar Circle, Ft. Collins, CO 80524.  Jan-Feb 1994, pp. 14 – 22.

Dryfoos, J.G. (1993) Preventing Substance Abuse: Rethinking Strategies.  American Journal of Public Health.  83; 793 – 795.

Education Issues Meetings (1999 and ongoing).  Proceedings at House of Lords.  Unpublished.  Contact The Baroness Cox for details.

Fukuyama, F.  (1999) The Great Disruption.  The Free Press. USA.

Markwood, A. (1999) Values Clarification development and diversion.  Markwood (unpublished). E-mail to this author 12 May 99.

Maslow, A. (1954).  Heirarchy of Needs, in Motivation and Personality Harper and Row, New York.  1954

Naylor, F. (1998).  Teenage Parenthood – submission to Social Exclusion Unit. Unpublished.
2, Kingsdown House, Kingsdown, Corsham, Wilts  SN13 8AX.

Naylor, F. (1999) Developments in Moral Education: paper presented to ‘Mut Zur Ethik’ conference, Feldkirch, Austria, 1999.  Naylor. 2, Kingsdown House, Kingsdown, Corsham, Wilts, SN13 8AX.

Phillips, M.(2000) ‘Britain is quietly turning into a drug culture’  Sunday Times,  9th Jan. 2000

Stoker, A (1999). D.A.R.E – An Overview of Research (also includes ‘What can be learnt from the Roehampton Review?’)  NDPA, P.O. Box 594, Slough, SL1 1AA.

Stoker, P. (1998). A Rational Approach to Drug Prevention in the Primary School: Practice Review and Policy Developments.  Early Child Development and Care.  1998. Vol. 139, pp. 73-97.

Stoker, P. (1999) Drugs and Professional Subculture. NDPA.  P.O. Box 594, Slough, SL1 1AA.

Towe, N. (2000) Drug Education Forum,  Letter to Editor of Sunday Times, 16th Jan 2000
The Times (of London)  ‘Say No Again’.  Times.  Editorial 15 May 1995.

Yankelovich et al. (1997) Cigarette Smoking among Teenagers and Young Women.  Dept of Health and Welfare.  Publication No. 16, National Institute of Health.  77; 1203.

A search was made to assess what research has been done in the areas of parent surveys and parent programmes for drug prevention with children – most research on drug prevention education has been done in the late 1970s, early and mid 1980s. In regard to parent surveys, a study entitled ‘Parents’ Attitudes Towards Drugs’ (International Research, Central Office of Information) was done in England and Wales (1985). This survey was the only one found and was administered some time ago. However, it assessed parents’ attitudes, beliefs and knowledge about drugs; whether parents or schools should be doing drug prevention work; how parents would cope if they found their children were using drugs; parental responsibility; whether parents had seen any drug abuse leaflets, ads, or other publicity; and the presence of a drug problem in their areas.

Pertinent findings from this survey included:

45% felt that there was a big drug problem in their area,
58% of parents believed they did not know enough about drugs,
87% said they would take total responsibility if they found out their child was using drugs (10% would take partial responsibility, 1% would not take any and 2% did not know).
A survey of youth attitudes in the same year included the question “If you had problems with drugs and wanted help, who would you turn to?” Of respondents, 56% mentioned one parent or both, specifically:
Mother: 23%
Father: 5%
Parents: 28%
Specific research on parental influence and the need for parental involvement in prevention programming showed the importance of parents. Many of these studies come from America. One study assessed family risk factors for alcohol and other drug use (Kumpfer, 1987). These risk factors included:
Parental dependency and family history of dependency
Parental psychological and social dysfunction
High levels of family conflict
Family social isolation
Special needs/special problem children
Non-nurturant and ineffective parenting
The family has been found to be very much involved in “the initiation, maintenance, cessation and prevention of drug use’ (Coleman, 1980). In assessing adolescent correlates, Young and West (1985) concluded that ‘the family has the greatest influence on alcohol and other drug use.” Family influences were cited as correlated with alcohol use in 52% of the articles reviewed, in 46% of the time in marijuana use, 80% of the time in illicit drug use and in 59% of the studies of general drug use. A 1984 study by Harford found that “both abstinence and drinking in parents are frequently paralleled by abstinence or drinking in their adolescent children.”
It has been found that “children are influenced most by the adults in their lives when they are young, prior to the onset of peer influence. Parents of young children should be aware of what they model for their children” (Benard, et al. 1987). Parents can influence children through even their use of prescription and over the counter medicines (Perkins and McMurtrie-Perkins, 1986). Research indicates that children are at greatest risk of beginning to use alcohol and marijuana before the age of 15, and thus, need to learn resistance skills “preferably before age 9 and no later than age 12. Fortunately, many children at these ages are opposed to drug use and are receptive to parents’ efforts to teach them skills that reinforce their current attitudes.” (Hawkins, et al. 1988).

In a 1987 study by Catalano of 10 to 15 year olds, 36% of 10 year olds, 54% of 13 year olds and 79% of 15 year olds had already refused an offer of alcohol or another drug. These students mentioned their parents most often as the single most important reason for refusing alcohol or other drugs. Hawkins (1988) also found that establishing a clear family position on alcohol and other drugs provides children with the motivation to refuse these offers.

Research on specific parent programmes for preventing drug use in children was difficult to find and one journal stated there is a need for more studies in this area. Family-focused programmes that improve parenting and family management skills are seen as promising prevention strategies for alcohol and other drug use. One reason for this is that parents “can be trained to be effective change agents and their effect will be enduring and powerful” Kumpfer (1988) and Alvy (1985) believed that parent training is “a necessary component of any comprehensive prevention plan that can affect a wide range of social and health problems.” Most successful programmes train parents by addressing effective parenting through groupwork, videos/films, games, manuals, and exercises. Practice in the home is encouraged to reinforce skills.

Bry (1985), after reviewing research on the topic, concluded that “family involvement is very important, if not essential, for positive outcomes in prevention programmes. She found that when families are included in school programmes, risk factors can be reduced and early signs of problems can be reversed. A l986 study showed that three months of targeted family problem solving training reduced drug use and a correlate (school-failure) by the end of a 16 month follow-up, while control group behaviours in this study remained the same.

From existing studies, it has been shown that when parents do attend a drug prevention education programme, they are responsive. It has been found that parents will change their approach to parenting, but behaviour has not been examined. Very few studies have examined changes in children as a result of parent training, but those that tested the children have shown reductions in their use of tobacco and alcohol (National Institute on Drug Abuse: Bry. 1983).

In some studies, even the parents reduced their use of tobacco and drugs (National Institute on Drug Abuse: Flay and Sobel, 1983). Also, it has been found that school-based efforts will be more successful if combined with a parent component (National Institute on Drug Abuse: Leukefeld, 1988).

Many different research designs have shown the effectiveness of parent training in reducing problem behaviours in children (1988). Parent training can help reduce children’s behaviours that are precursors of drug use and increase positive behaviours such as school achievement, social skills and family involvement (Stouthamer-Loeber, 1986).

Three other studies were found that examined parent programmes. However, in all cases, the parent programme was a component of more comprehensive programming and was not individually assessed. For example, a 1987 study examined a school programme which included parent groups to learn about the drug problem and monitor their children’s behaviour, community meeting with key community members; coalitions and work in schools (teacher education, prevention curricula and policy). This comprehensive programme was found to decrease drug related incidents in the school and improve academic achievement.

Another prevention project including parent education and organisation, school-based education for children, mass media programming, community organisation and health policy was assessed in 1989 (Pentz, Dwyer, et al). There were 42 schools that participated and were assessed. Findings showed that prevalence rate for cigarettes, alcohol and marijuana were significantly lower at the one-year follow-up study. The net increase in drug use prevalence in schools receiving prevention programming was half that of other schools.

Finally, “Family Effectiveness Training” was assessed in 1989 (Szapocznik, Santisteban, et al) and looked at families who had the risk factors for developing a drug abusing adolescent. Results showed that families undergoing this training had greater improvement than did control groups on measures of family functioning, problem behaviour by adolescents and child self concept. Results were maintained at a six-month follow-up study.

Source: Susan Kaplin, Research Officer. Life Education Centres. April 1992 updated 1997.

Introduction
Several reviews of the substance abuse prevention literature have concluded that social-influence-based prevention programmes can significantly delay the onset of tobacco, alcohol, and other drug use and slow the rate of increase in substance use prevalence among entire populations of early adolescents. Less is known about the capacity of these and other primary prevention programmes to effect decreases in substance use. This is an important question, since some youth have already begun to experiment with drugs by the time that usual primary prevention programmes have reached them. Youth exhibiting early drug use relative to their peers are considered at higher risk for later drug use and abuse. The few studies that have investigated the effect of primary prevention programmes on those who have already begun using tobacco or other drugs have yielded equivocal results and have not systematically evaluated maintenance of decreases in use. The purpose of this study was to evaluate the secondary prevention effects of a primary prevention programme in reducing cigarette, alcohol, and marijuana use among baseline users.

Abstract
Objectives. This study investigated the secondary prevention effects of a substance abuse primary prevention programme.
Methods. Logistic regression analyses were conducted on 4 waves of follow-up data from sixth- and seventh-grade baseline users of cigarettes, alcohol, and marijuana taking part in a school-based programme in Indianapolis.
Results. The programme demonstrated significant reductions in cigarette use at the initial follow-up (6 months) and alcohol use at the first 2 follow-ups (up to 1.5 years). Models considering repeated measures also showed effects on all 3 substances.
Conclusions
Primary prevention programmes are able to reach and influence high-risk adolescents in a non-stigmatizing manner.
Discussion
Primary prevention programmes have been criticized for affecting future occasional users but not youth at the highest risk for drug abuse (e.g., current users). In this study, we reported 3.5-year follow-up effects of a primary prevention programme in decreasing drug use among adolescents who were users at either sixth or seventh grade. With a very conservative criterion to define decreased use, the results indicate that the programme did effect reductions in use, especially cigarette and alcohol use. These secondary prevention effects were significant for cigarette users at the 6-month follow-up and marginally significant at the 2.5-year follow-up. Effects were also found among baseline alcohol users through the 1.5-year follow-up. Consistent with other prevention studies, the effect sizes were small for cigarettes (range: .05-.31) and alcohol (range: .08-.24) and medium for marijuana (range: .38-.58). Although no significant effects were detected among baseline marijuana users, it is important to note that the programme group consistently demonstrated greater reductions in all 3 substances across all follow-ups, except marijuana at the 3.5-year follow-up. When the secular trend was also considered, the Midwestern Prevention Project consistently showed significant secondary prevention effects on cigarette, alcohol, and marijuana use.

There are several methodological limitations to this study. For example, a possible threat to the validity of the findings was the reliance on self-reported drug use. However, extensive research conducted on the validity of self-reported smoking dispels this concern, especially if a bogus pipeline activity is built into the procedures for data collection, as was done in the present study. Another possible limitation is that measurements were limited to a fixed point in time (previous month) from year to year, thus leaving open the possibility that the last reported use level may have been an under-estimate of actual normal use patterns. However, given that this study was fully randomized, the programme and control groups should have been equal in regard to their validity estimates of the point prevalence of drug use measured.

This research suggests that social-influence-based primary prevention programmes can have an impact on not only students who are nonusers at baseline but also those who have begun to use drugs. The advantage of such a primary prevention programme is that it may reach and affect a ‘silent’, not-yet-identified, high-risk population of early drug users in a nonstigmatizing , nonlabeling fashion at an age when youth are more easily persuaded (treating the young users, in effect, like nonusers contemplating use).

Source: Chih-Ping Chou, PhD, et al. American Journal of Public Health, June 1998, Vol.88, No6