CND 52ND Session – Vienna International Centre
Side Event – 18th March 2009
Effective Programmes for Drug Prevention in Youth
by Peter Stoker – Director, National Drug Prevention Alliance, UK.
This paper is written in the context of education for Universal Prevention, rather than for Indicated or Selective Prevention processes.
Drug education, as we on the prevention side of the house understand it, is part of the process of producing drug-free lifestyles for all. But our opponents characterise and condemn this as part of a so-called ‘war on drugs’.
Well, if what we have here is indeed a ‘war’, should Obama pull the troops out? More realistically, this is a ‘war’ that has never been fought for real. And sadly those whom you might think of as ‘our’ troops too often turn out to be collaborators. With the benefit of hindsight we can see that the term ‘war on drugs’ is a finely conceived and executed meme (Ref 1 – a paper by my NDPA colleague Brian Heywood – will tell you more about what a meme is) – this particular meme engenders a feeling that we who are opposed to drug abuse are aggressors, whilst our opponents, the libertarians, are cast as peace-seekers. Their high priests, such as Arnold Trebach, exploit this meme by pleading that ‘… we have had enough ‘drug war’ – what we want now is a little ‘drug peace’’. As Mel Brooks might have put it:
“A little piece of heroin, a little piece of dope,
A little piece of cocaine, brings us peace – we hope.”
Whether you seek a drug-free society, or the kind of drug-laden ‘peace’ Arnold Trebach proposes, both camps see a key role for drug education. Surely this means that if we serve up more education than they do, we will reach our goal – right? Wrong. This is the kind of over-simplifying that has typified too much of what has been done in the name of drug education in the past – it is like serving yourself chicken soup at home – it gives you a warm feeling, but nobody else notices.
After nearly twenty years of PRIDE conferences I can recall several drug education programmes which would have ‘warmed the soup’ for the teacher – but done little else.
Taking the title of this paper – ‘Effective Drug Education for Youth’ – let me start by de-constructing the title – in reverse order:
‘Youth …’
There are not a few people around – present company excepted – who see drug education with youth as the Silver Bullet. Get this youthful generation ‘educated’ and we are home and dry (and clean and sober). I take issue with this – youth are not an island, even though they are as vulnerable as any, and more vulnerable than many, to external influences – what the professionals call ‘mediating variables’. And youth have an inexhaustible knack of grabbing the wrong end of the stick; I still relish the words of one American mentor, several years ago:
‘There’s nothing wrong with a teenager that reasoning with him
won’t aggravate’.
Just to remind us all that youth are not the be-all and end-all, I draw your attention to a report on evidence-based prevention with ‘older adults’ – published under the auspices of SAMHSA (Substance Abuse and Mental Health Services Administration) by the ‘Older Americans Substance Abuse and Mental Health Technical Assistance Center’. The problem of substance abuse amongst senior citizens is recognised to be such as to require prevention to be ‘a national priority’. (Ref 2)
‘Drug Education …’
I am astonished to note that there are still teachers around who think the transfer of factual knowledge is the key to drug prevention success. One may comfort oneself on the excellence of one’s knowledge transfer, and be warmed by a few positive feedbacks; the acid test is ‘have you influenced the majority?’ – the acid answer is ‘probably not’. Of course facts on their own will be seminal for a few receiving them – we have all, in our time, been touched by a single fact – but one cannot in all seriousness extend this to a generality.
We need to recognise that drug education is not an end in itself, it is a tool of prevention, and as such it must help must mediate behaviour. You can deliver a programme of education which satisfies process criteria within itself – but it has long been known that transmitting knowledge does not automatically change behaviour.
A valuable and occasionally seminal tool, maybe, but unless it is delivered skilfully, and in the right setting, unless it is properly sharpened, it won’t cut it.
‘Effective …’
My contention, from the review above, is that concentrating on ‘youth’ and ‘drug education’ in isolation cannot (for most recipients) be effective in terms of drug prevention. If we are looking for effective lifestyle change, then we have to look much wider and more rationally.
The current US-based point of reference for effective processes of prevention is NIDA. (National Institute on Drug Abuse). Their most recent summary on the subject is ‘Preventing Drug Use – A Research Based Guide – second edition’ – 2003. (Ref 3) It is interesting to note that this reference work is now more than six years old. Does this mean it cannot yet be improved upon? Have fashions changed? Or is it simply a shortage of funding for prevention research?
The Guide starts by setting out the Principles of Prevention, under sixteen main headings. Of these, Principles 7 and 8 – reproduced here as Table 1 – focus on education, saying:
Principle 7- Elementary Schools – ‘… programs should target improving academic and social-emotional learning’.
Principle 8 – Middle, Junior and High schools – ‘…programs should increase academic and social competence’
The Guide does give a useful reference list of the components of effective preventive education, but this does not seem to take us much further than the earlier work (Ref 3) by Bonnie Benard, when she was a specialist with Illinois Teen Institute in the 1980s. Benards’ recommendations are shown in Table 2.
What neither NIDA nor Benard do not mention is the single factor which can be said to encompass all other factors in influencing (mediating) behaviour. That factor is culture.
This means the culture in which decisions about drugs are made; the culture in which teachers, police, media, legislators, governments, medics, youth workers, parents, partners (and many more besides) operate in this society of ours. The culture impinging on the decision-making person and their interaction with the culture of all other people around them is a major part of this. The age of all concerned is also relevant – as is the ‘education’ they have received. We sometimes forget that teachers in drug education have often received little or no education on the subject themselves, or in some cases, may have been exposed to influence from teacher trainers who have a drug education axe to grind. (Indeed some of these teachers may be current or past users of drugs themselves).
So, what influences the culture around decisions? Ii includes, in no particular order:
– Peer Group Influence
– Personal perceptions
– Income v Cost of any action
– Health Issues
– Moral Structure
– Spiritual structure
– Family values
– The attraction of risk-taking
– The media, music, movies, tv, fashion, humour etc.
– Mental condition, – depressed, elated, in-between, and
– Legislation, including Conventions
This primacy of culture resonates with the work of one of my earliest mentors, Bill Lofquist, (Ref 5) who hails from Tucson, Arizona and who said:
“We need to get beyond the notion that prevention is stopping
something happening, to a more positive approach which
creates conditions which promote the well-being of people.”
Addressing culture through education is ‘creating conditions’ – no more and no less.
If you are going to tackle the culture in a community, you would do well to first measure whether your seeds will fall on stony ground, or will bear fruit. The NIDA Guide usefully assists this by giving a check list ‘Nine Stages of Readiness in a Community’ – reproduced here in Table 3.
Specifics of Effective Drug Education for Youth
Too often, it seems, the approach to drug education takes for granted that the educators understand and buy into the intended goals, know what they are doing, and will operate a Systems Approach – such as that described in another invaluable reference tool – ‘The Future by Design’. Published by the USDHHS, Department of Health and Human Services, in 1991. The core of a systemised approach is a ‘spiral’ of revisiting process stages – plan/implement/evaluate/decide/then plan again.
Another gem from this valuable reference work is a table showing a ‘Contrast of Paradigms’ in empowering a community – whether this be an education community or some other part of society. Reproduced herein as Table 4, it will almost certainly have a salutary effect on all of us, whatever our professional discipline !
As a very recent example of effective prevention programmes. I cite the ‘Good Behavior Game’ developed and tested in Baltimore City Public Schools, and reported in 2008 ( Ref 7 and Ref 8). Addressing multiple targets – anti-social disorders, violent and criminal behaviour, disruptiveness, as well as drug abuse and other factors, the ‘GBG’ program applied classroom management techniques with more than 2300 pupils, and helped them to significantly adjust to the role of successful student. A positive impact on drug/alcohol abuse was but one of the measured positive outcomes.
How Does Effective Education Fit In?
America’s CSAP (Centre for Substance Abuse Prevention) – was excited as long ago as 1991 (Ref 6 – see Chapter 1, Overview) by the finding that the best prevention results come through ‘….co-ordinated prevention efforts that offer multiple strategies, provide multiple points of access, and coordinate and expand citizen participation in community activity.’
Such an approach , whether in drug prevention or drug education, requires a certain relinquishing of self-authority; to get the best out of a wide range of disciplines and sectors, it is expedient to get on to their level – whatever that is. Prevention expert Bill Lofquist spells this out clearly by defining a spectrum of approaches – you can treat youth as dumb ‘Objects’, as ‘Recipients’ – albeit under your control, or as ‘Resources’ sharing the policy and practice. Hard way or easy way – your choice. It is also important to recognise that you cannot ‘do’ prevention ‘to’ people, you must rather engender a condition in which prevention will be the obvious choice for people.
This is also to a significant extent true of drug education – and certainly of affective education.
Equally important is an understanding of how the drug education which you are delivering interacts and harmonises with the whole societal system, and the goals of each sector. An example of this is given in Table 5 herein, which was presented by NDPA to the UK Shadow Home Secretary’s Office last November (2008) as part of a dialogue on national drug policy.
Specific examples of Effective Prevention
The technical references called up in this paper give several specific examples, covering various approaches. NDPA can give extended details (on request) on its own Peer-led drug education and prevention process – Teenex ( Ref 9 )– which was successfully adopted by other countries.
If you are looking for support for prevention, your first place to look would probably not be The Economist, and yet their issue on 5th March this year gave just that. Their Article entitled ‘In America, lessons learned’ ( Ref 10) says:
‘By far the best way of reducing the harm that drugs do is to convince
people not to use them’
The Economist article gives several further encouragements to preventive drug education. It takes the usual swipes at the DARE (Drug Abuse Resistance Education) programme, and does so on the usual incorrect and outdated basis, but it finds itself compelled to move to a more complimentary stance when it describes the latest remodelling, including DARE’s much wider scope of linked subjects – from drugs to internet bullying.
As the Economist observes, DARE (Drug Abuse Resistance Education) programme has learnt this lesson the hard way. DARE’s current strapline is ‘Dare to resist drugs, and violence’ and despite the hostile attitude of some on both sides of the drug education house towards it, DARE continues to succeed, witness the fact that it has been taken up by another 220 communities in the three years to its latest published report (2007).
Another project lauded by the Economist for a multi-topic motivational approach started in Montana and other western states in tackling the resurgent problem of methamphetamine abuse. Instead of trotting out the usual array of medical harm facts, the organisers elected to highlight that meth users often get rotten teeth. This turned out to be a very telling message.
The Economist concludes its article by referring to the anti-tobacco campaigns, which have made big inroads into prevalence. They suggest several reasons for this success; I would suggest they can all be grouped under the heading of culture change.
Elsewhere, an interestingly different example is given in the NIDA research-based guide. It is called PATHS – Promoting Alternative Thinking Strategies, and it is a programme for ‘promoting emotional, health and social competencies, and reducing aggression and behaviour problems in elementary school children, while enhancing the educational process in the classroom’. Although primarily targeted at school classrooms, it also includes information and activities for parents. I draw your attention to this programme not so much for its particular excellence as much as its example of how diverse one’s drug education approach can and should be. Diversity in a programme may produce vital dividends in this time of scarce funding. If the programme you intend using has other benefits over and above drug education, then this could open the door to other funding sources. Diverse outcomes equals diverse incomes!
Conclusions
With the aim of ‘Effective Drug Education for Youth’ we need to understand that what makes a programme effective will range well beyond the programme itself. Taking an extreme example, if , as has been asserted, drug abuse is a reaction to an unsatisfactory society, then the solution is simple – improve society!
This paper has attempted to take drug education out of its comfort zone, and in the process, to identify ways of improving effectiveness.
One way to concentrate one’s thinking about drug education is to consider it as a business venture. Metaphorically speaking, what are the parameters we should address in this business?
– What is our product, our USP?
– What can we sell it for, and to whom?
– What can the competition sell theirs for and to whom?
– Where can we best sell it?
– Who, besides us, can influence the market?
– Who has the best toys? And can we partner with them?
– What is the shelf life of our product?
– What is our human resource? and
– How are we going to measure sales?
I wish you every good fortune, as you draw up your Business Plan!
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REFERENCES
1. Heywood, B. ‘Assaying Information in the Substance Misuse World’ Published NDPA, 2004
2. Blow, C. F. et al ‘Evidence-Based Practices for Preventing Substance Abuse and Mental Health Problems in Older Adults’ Published: Older American Substance Abuse & Mental Health Technical Assistance Center, 2005.
3. National Institute on Drug Abuse. ‘Preventing Drug Use Among Children and Adolescents – A Research- Based Guide’ Published NIDA, Second Edition 2003.
4. Benard, B. ‘Characteristics of Effective Prevention’ Published Project Snowball training manuals, Illinois Teen Institutes, 1987.
5. Lofquist, W.A. ‘Discovering the Meaning of Prevention – A Practical Approach to Positive Change’, Published: AYD Publications, Tucson, Arizona l983. Fifth Printing, 1991.
6. OSAP, DHHS. ‘The Future by Design – A Community Framework for Preventing Alcohol and Other Drug Problems Through a Systems Approach. Published: DHSS No. (ADM) 91-1760; l991
7. Petras, H. et al. ‘Developmental Epidemiological Courses Leading to Antisocial Personality Disorder and Violent and Criminal Behavior; Effects by Young Adulthood of a Universal Preventive Intervention in first-and second-grade Classrooms’ Published: Drug and Alcohol Dependency, 95S1 – pp.S45-S59, 2008
8. Poduska, J. et al. ‘Impact of the Good Behavior Game, A Universal Classroom-based Behavior Intervention, on Young Adult Service Users for Problems with Emotions, Behavior, or Drugs or Alcohol. Published: Drug and Alcohol Dependency, 95S1 – pp.S29-S44, 2008
9. Stoker, S. A. ‘Teenex – ‘A Peer Education and Drug Prevention Programme’ Published National Drug Prevention Alliance, 1988 and subsequent editions.
10. Economist,print edition. ‘In America, lessons learned – but efforts to warn people off drugs are still too timid’. – March 5th 2009
Table 1.
NIDA: ‘Preventing Drug Use, Research-based Guide’ – 2nd Edition, 2003.
Prevention Principles – Extract for Education
Principle 7:
Prevention programs for elementary school children should target improving academic and social-emotional learning to address risk factors for drug abuse, such as early aggression, academic failure, and school dropout. Education should focus on the following skills (Ialongo et al. 2001; Conduct Problems Prevention Work Group 2002b):
- Self-control
- Emotional awareness
- Communication
- Social problem-solving; and
- Academic support, especially in reading.
Principle 8:
Prevention programs for middle or junior high and high school students should increase academic and social competence with the following skills (Botvin et al. 1995; Scheier et al. 1999):
- Study habits and academic support;
- Communication;
- Peer relationships;
- Self-efficacy and assertiveness;
- Drug resistance skills;
- Reinforcement of anti-drug attitudes; and
- Strengthening of personal commitments against drug abuse.
NOTE: Principle 9 is also relevant, in encouraging programs aimed at transition points, such as the transition to middle school; these “…can produce beneficial effects even among high-risk families and children”.
(Botvin et al. 1995; Dishion et al. 2002).
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Source document full title:
‘Preventing Drug Abuse among Children and Adolescents – A Research-Based Guide for Parents, Educators, and Community Leaders’. Second Edition 2003.
National Institute on Drug Abuse/ US Department of Health and Human Services.
Available on line throughwww.drugabuse.gov
Table 2
Characteristics Of Effective Prevention
Written by Bonnie Benard, NIDA, USA.(Originally in training manuals for Project Snowball, Illinois Teen Institutes, 1987)
Published in Britain in ‘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. In Britain 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 in Britain, 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 (in America 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.
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Table 3
NIDA ‘Preventing Drug Use’ – A research-based guide Measuring Community Readiness for Prevention
AS SIMPLE AS A,B,C.
(A) ASSESSING READINESS (B) COMMUNITY RESPONSE (C) IDEAS
Source: Plested et al, 1999.
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Table 4
DHHS – OSAP (CSAP) – ‘The Future by Design’
Community Action Alternatives
Community Empowerment System:
a Contrast in Paradigms
How do you want this project or program to run ? You can choose either the paradigm of (A) Agency delivery of Services OR the paradigm of (B) Community Empowerment – Which is it to be ?
Here are the results you could encounter:
1. (A) Professionals are responsible (doing for the community) OR (B) Responsibility is shared (doing with the community)
2. (A) Power is vested in agencies OR (B) Power resides with the community
3. (A) Professionals are seen as experts OR (B) The community is the expert.
4. (A) Planning and services are responsive to each agency’s mission OR (B)Services and activities are planned and implemented on the basis of community needs and priorities
5. Planning and service delivery are fragmented OR Planning and service delivery are interdependent and integrated.
6. Leadership is external and based on authority, position and title OR Leadership is from within the community, based on ability to develop a shared vision, maintain a broad base of support, and manage community problem solving.
7. Ethnic and cultural differences are denied OR Ethnic diversity and special populations are valued.
8. External linkages are limited to networking and co-ordination OR Co-operation and collaboration are emphasized.
9. The decision making process is closed OR Decision making is inclusive.
10. Accountability is to the agency OR Accountability is to the community.
11. The primary purpose of evaluation is to determine funding OR Evaluation is used to check program development and decision making.
12. Funding is categorical OR Funding is based on critical health issues.
13. Community participation is limited to providing input and feedback OR Community is maximally involved at all levels.
Table 5
Submission to UK Shadow Home Office Drugs Minister
by NDPA
An Idealised UK Drug Strategy should contain:
Culture change: – Cross-society measures coordinated to produce a
result, as has been done with tobacco.
Information: – Improve quality, age-appropriateness, root out hidden messages.
Prevention: – Few know what it is, fewer practice it. Study it. Apply it.
Show its cost-benefit to society as a whole.
Education: – Abstinence goal. Check materials before allowing them into schools. Develop random drug testing
.
Intervention, Treatment, Rehab, After-care, All should be abstinence-oriented
Justice system: – Apply proven systems such as Drug Courts. Work towards drug-free prisons. Apply mandatory education courses to any person cautioned or convicted.
Policing: – Should include referral to education courses
Customs:- Address serious concerns about SOCA
NICE – Should embrace an abstinence focus
Harm Reduction: – Should apply to whole society, not just users
Human Rights: – Should apply to whole society, not just users
Policy reviews: – Should proceed in line with the above goals.
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Guide to acronyms:
NICE National Institute on Clinical Excellence
SOCA Serious and Organised Crime Authority