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Prevention of Substance Use Disorders 

Prevention of Substance Use Disorders
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Prevention of Substance Use Disorders
DOI:
10.1093/9780195173642.003.0020
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date: 15 August 2018

On the basis of findings from extensive epidemiological research, the Centers for Disease Control and Prevention (CDC) has identified a set of interrelated problem behaviors, typically originating during childhood and adolescence, that are critically important from a public health standpoint. For youths, central among these risk-related health behaviors are alcohol, tobacco, and other drug use (CDC, 2002b). Prevalence rates of alcohol, tobacco, and marijuana use among adolescents remain high. For example, recent prevalence of lifetime alcohol use among 12th graders was 80%; for cigarette use the lifetime rate was 64.7%, and for marijuana it was 49.7% (Johnston, O'Malley, & Bachman, 2000). Early initiation and use of these substances are associated with a wide range of problems, including risky sexual practices, impaired mental health functioning, and behaviors that result in unintentional and intentional injuries (CDC, 2002a; Duncan, Duncan, Strycker, Li, & Alpert, 1999; Windle & Windle, 2001). Thus, legal and moral implications aside, adolescent substance abuse must be regarded as a public health issue. The effective prevention and treatment of adolescent substance abuse, like that for any public health problem, require a clear understanding of causes and the context in which these causes operate. One cannot effectively stem a pneumonia epidemic without knowing the following:

  • Which microbe or microbes produce the disease?

  • Under which environmental conditions do the microbes flourish?

  • Are there individual sensitivities to the infection?

  • What are the most common patterns of contagion?

  • To which antibiotic treatments are the microbes most sensitive?

  • What are the patterns and factors associated with relapse?

Research on the origins of adolescent substance abuse is asking similar questions: How do different drugs affect the brains of different adolescents at different stages of maturation? How do environmental conditions increase or decrease the probability of substance abuse? Are there individual sensitivities to drugs of abuse that increase the risk of a substance use disorder? How do social factors produce contagion of drug abuse among adolescents? Are there specific treatments or prevention interventions for specific types of adolescent substance abuse? How do biological, psychological, and social factors account for failed prevention efforts or drug treatment relapse, and how common is it? This promising body of research carries with it the potential to create more effective approaches to the prevention of adolescent substance abuse as well as guiding treatment efforts.

THEORETICAL AND CONCEPTUAL MODELS OF PREVENTION AND CHANGE

There is no generally agreed-upon theoretical or conceptual model for prevention of substance abuse. Most prevention interventionists and researchers use both theory and empirical research to plan prevention programs. For example, Hawkins and colleagues Hawkins, Catalano, & Miller, (1992) derive a psychosocial model of drug abuse prevention based on an etiological model that incorporates laws, social norms, substance availability, the quality of the neighborhood, peer values, peer behavior, parental values, parental behavior, individual values, and individual behavior. However, there is no widespread agreement that these domains are the most salient in the cause or prevention of a drug abuse disorder. The development and implementation of a prevention intervention that efficaciously addresses all of these broad domains are daunting tasks.

RISK AND PROTECTIVE FACTORS: THE COMPLEX CAUSES OF ADOLESCENT SUBSTANCE ABUSE

It has been recognized for over 30 years that the risk for becoming a substance abuser is not equally distributed in the population. Originally this observation came from research that followed children into adulthood and used childhood demographic and psychological data to uncover pathways to an adolescent or adult sub stance abuse disorder. Subsequently, this view was bolstered by epidemiological surveys in the United States that revealed that only 27% of individuals who have experimentally used drugs six or more times actually progress to become daily drug users, and only about a half of young adult daily drug users go on to develop a drug abuse or dependence disorder (Robins & Regier, 1991). While it is possible that chance plays a role in the acquisition of a substance abuse problem, it is more likely that the complex interplay of risk and protective factors determine who progresses from experimentation to regular use and from regular use to problematic involvement. Furthermore, the interplay of risk and protective factors exists in a maturational context such that at some stages of human development certain biological, psychological, or social factors may be totally benign, while at other stages of development these same factors may confer considerable risk for problematic involvement with drugs of abuse. These risk factors are subject to effects of gender and ethnicity, so risk factors may operate differently in boys and girls, and in Caucasians and African Americans. To further complicate the issue, individual risk and protective factors must be viewed against a backdrop of laws, cultural and social norms, drug availability, economic circumstances, and regional and community factors. For example, a white Chicago adolescent male who has a variety of individual risk factors for alcoholism might develop alcohol problems, but if that same child were raised in Saudi Arabia (where drinking alcohol is forbidden), it is less likely that he would develop an alcohol problem. However, it is possible that these risk factors might manifest themselves in other forms of problematic behavior (e.g., aggressive behavior). Thus, substance abuse is a multifaceted problem.

Geneticists refer to multidetermined problems like substance abuse as “complex disorders” because a multiplicity of individual biological and behavioral factors interact with environmental factors (e.g., social and societal phenomena) in complicated ways across human development to produce a good or bad outcome. To the best of our knowledge, there is no single cause of adolescent substance abuse, and so it is unlikely that there will be a single preventive measure to forestall its development. For this reason, the reader is cautioned to be skeptical of overly simplistic causal explanations for substance abuse problems and of facile and obvious solutions. The likelihood that approaches guided by conventional wisdom will achieve their promised results is diminished by the realities of our current understanding of the complex pathways to a substance abuse disorder.

INFLUENTIAL THEORIES OF THE DEVELOPMENT OF ADOLESCENT SUBSTANCE ABUSE

Theories develop as an effort to summarize and explain research data generated by observation and experimentation. Theories are used to organize future research studies that ultimately test the validity of the original theory and provide an opportunity for the initial theory to evolve and undergo revision. Thus, theories are scientific “works in progress,” not facts. Several influential theories have guided our understanding of the origins of adolescent substance abuse, and provide a framework for ongoing research in this area. These theories also provide a useful structure to guide approaches to the prevention and treatment of adolescent substance abuse problems. The following are among the most influential of these theories. There are many areas of commonality and overlap; yet each has contributed and advanced our understanding of the origins of substance abuse. Other theories abound and it is noteworthy that the “general field theorem” for the vulnerability to adolescent substance abuse has yet to be fully articulated.

The “Gateway” or Stage Theory

This theory comes from epidemiological research that has examined the patterning of alcohol and other drug use progression among adolescents. However, recently this theory has become a battleground for those both for and against the decriminalization of marijuana. The theory is based on the delineation of four stages in the sequence of involvement with drugs. The original findings suggested that surveyed adoles cents engage in use of either alcohol or cigarettes (as legal and culturally accepted drugs) then progress to marijuana, and then on to other illicit drugs, such as heroin and cocaine. The legal drugs are necessary intermediates between nonuse and marijuana. Thus, the use of tobacco, alcohol, and marijuana by adolescents was viewed as a crucial step, or “gateway,” to the use of other illicit drugs (Kandel, 1975). However, opponents of this theory suggest that, if there were a risk factor that was common to both marijuana and other drugs, it could easily account for the relationship between both marijuana and other drug use. Examples of a theorized “third factor” include the genetic predisposition to drug use, a predisposition toward adolescent risk behavior in general, or shared opportunities to obtain both marijuana and other drugs (Morral, McCaffrey, & Paddock, 2002). Nonetheless, surveys of American high school students suggest that by 12th grade, 37% of students have tried marijuana, whereas 0.9% have tried heroin and 4.8% have tried cocaine (Johnston, O'Malley, & Bachman, 2002b). The discrepancies in these prevalence rates indicate that although hard drug users may have started with marijuana, it is clear that marijuana use does not invariably progress to adolescent use of hard drugs.

A less controversial aspect of this theory deals with age of initiation of experimentation with drugs of abuse (whether it is alcohol, tobacco, marijuana, or hard drugs), and the timing of stages of regular use and problematic involvement. The literature converges around the observation that the earlier the onset of substance use, the greater the likelihood of problematic involvement (Choi, Gilpin, Farkas, & Pierce, 2001; Choi, Pierce, Gilpin, Farkas, & Berry, 1997; Kandel & Logan, 1984; Schuckit & Russell, 1983; Yamaguchi & Kandel, 1984b). For this reason, substantial effort has been placed on prevention interventions that delay the initiation of initial substance exposure.

Problem Behavior Theory

Problem behavior theory is an influential conceptual framework for understanding not only substance abuse but a wide variety of other types of risky adolescent behaviors (Jessor & Jessor, 1977). The theory proposes that there exists a syndrome of adolescent problem behaviors that may co-occur within the same individual (Jessor, 1991). For example, those who experiment with substance use also tend to engage in risky sexual practices and illegal behavior. These adolescent problem behaviors include

  • Problematic involvement with alcohol

  • Illicit drug use

  • Delinquent behaviors (e.g., truancy, petty theft, vandalism, lying, running away)

  • Risky and precocious sexual activity

  • Other high-risk behaviors (e.g., drag racing, driving drunk)

These deviant behaviors are thought to emanate from a single underlying factor (perhaps of genetic origin) that may exist prior to adolescence, resulting in a general syndrome of deviance. The risky behaviors may also be adaptive to the extent that they serve a social or maturational goal, such as separating from parents, achieving adult status, or gaining peer acceptance, and these behaviors may help an adolescent cope with failure, boredom, social anxiety or isolation, unhappiness, rejection, and low self-esteem. One example of a risk behavior syndrome is an adolescent's reported use of substances as a means of gaining social status and acceptance from peers and, at the same time, enhancing mood and feelings of low self-worth (DuRant, 1995; DuRant, Getts, Cadenhead, Emans, & Woods, 1995). Thus, this theory posits that substance abuse for some adolescents may be a maladaptive means to cope with the stresses and social pressures that are characteristic of the adolescent stage of development. This theoretical perspective suggests that prevention interventions that offer alternative means of coping and social adaptation might reduce adolescent substance use behavior.

Patterson's Developmental Theory

Patterson's theory was originally proposed to explain the development of juvenile delinquency, and however consistent with the observation that problem behaviors frequently co-occur in adolescents, it has also been used to understand and address problematic involvement with alcohol and other drugs of abuse. Patterson and colleagues (Dishion, Patterson, Stoolmiller, & Skinner, 1991; Patterson, DeBaryshe, & Ramsey, 1989) are proponents of a developmental theory of conduct problems that posits that adolescent problem behavior is a consequence of poor parental family management practices interacting with the child's own aggressive and oppositional temperament. Here, temperament refers to the early and genetically determined behavioral characteristics that over time and life experiences evolve into personality. Deficits in parenting skill, such as harsh and inconsistent punishment, increased parent–child conflict, low parental involvement, and poor parental monitoring, result in school behavior and performance problems. The poorly performing and poorly behaving child may be socially rejected by average children, but he or she forms close friendships with other problematic children. This process of forming close peer relationships is augmented by the negative interactions with caregivers in the home.

As the child affiliates with more deviant children, he or she adopts deviant behavior as a norm and becomes less involved in home life. Other deviant children become powerful social role models from whom the child learns further deviant and socially unacceptable behavior, including experimentation with drugs of abuse. Early experimentation has consistently been found as a risk factor for later problematic involvement with a wide variety of drugs. These children may therefore be viewed as being on a developmental trajectory of deviancy and substance abuse that begins in infancy and is compounded by unskilled parenting and the formation of social relationships with other problem children (Vuchinich, Bank, & Patterson, 1992).

Prevention interventions based on this theoretical approach offer parenting skill training to teach parents more effective ways to discipline and monitor their children and reduce the negative environment of the home. Tutoring and other forms of education support may be provided to reduce academic failure. Social skills training may also be offered the child to reduce normal peer rejection and provide a mechanism to gracefully resist peer pressure to use alcohol and illicit drugs.

Behavior Genetic Theory: Adolescent Substance Abuse as a Complex Familial Trait

Plutarch noted 2,000 years ago that alcohol problems run in families (“Drunkards beget drunkards”; Plutarch, The Training of Children, 110 CE). More recently, research continues to demonstrate that there is significant familial aggregation of substance use disorders. If substance abuse problems run in families, then there must be some familial influence on the development of these problems. The behavior genetic theory proposes that those factors that are transmitted within families tend to make family members more similar on a given characteristic such as substance abuse. These within-family factors can be genetic, since parents, children, and siblings share about 50% of their genes; or they can be nongenetic. These nongenetic family factors include the modeling of behaviors, the teaching of values and beliefs, parenting practices, the structure of the home environment, the quality of neighborhood, and the standards of the society at-large in which the family lives. Those factors experienced uniquely by each family member tend to make family members different from each other. These nonshared factors include peers, work, school, and all aspects of life experiences outside the family. In families where there is little substance abuse but there is an adolescent with substance problems, it is less likely to be due to a family factor than to an unshared factor outside the family. If there are many within the family with substance abuse problems, then these are likely to be due to something in the family—either genes, the home environment, or the complicated effects of genes and environment working together.

Substantial evidence suggests that substance abuse, for both adolescents and adults, is a complex trait. However, while research clearly reveals that genes are an important determinant for substance abuse problems, it does not tell us which genes. For other complex traits such as high blood pressure or diabetes or high cholesterol, it is clear that there are multiple genes involved and multiple genetic and biological pathways are involved in producing disease. It is unlikely that there is a single gene for alcoholism or cocaine dependence or cigarette addiction. There may be hundreds or thousands of genes in a given pattern producing risk, and that risk may only be present in a given environmental context. The nature of the genetic risk may be a common factor for abuse across a wide variety of drugs or a genetic risk for conduct difficulties or problem behaviors, or a set of genes that delay the maturation of the brain so one is less able to control the habituating effects of drugs. The effects of genes may be protective rather than associated with risk, and what we think of as genetic effects producing substance abuse may actually be the absence of protective genes. There is good evidence that specific genetic mutations protect against the development of alcoholism in certain ethnic groups, and some evidence that there is a mutation that protects against smoking.

Applying New Knowledge of Genetics to Reduce Adolescent Smoking

The enormous toll that tobacco use takes on youth may also lead prevention experts to consider ways in which genetic risk information might be used to identify high-risk subgroups that might benefit from more intensive or tailored prevention approaches. As reviewed in greater detail elsewhere (Lerman, Patterson, & Shields, 2003; Wilfond, Geller, Lerman, Audrain-McGovern, & Shields, 2002), there are many ethical challenges and considerations. From a scientific perspective, research on genetics and tobacco use is still in its infancy. There is no single “tobacco use gene,” and as such, risk estimates will need to take into account multiple interactions between genetic, social, and psychological factors. Even considering genetic variants with widely validated effects on smoking behavior, these effects are likely to be small, and risk estimates will be highly probabilistic. Additional risks of genetic testing of adolescents include stigmatization, discrimination, and potential adverse psychological effects (Lerman et al., 2003).

Nonetheless, it is tempting to consider whether individualized feedback about genetic susceptibility to tobacco addiction could overcome adolescents' perceptions of invulnerability and reduce the chances of initial tobacco use or the transition to tobacco dependence. Despite acknowledging that nicotine is an addictive chemical, a large proportion (62%) of adolescents who smoke cigarettes report that quitting smoking was either easy or manageable for most people if they tried hard enough (Jamieson & Romer, 2001). Likewise, data from the 2002 Legacy Tracking Survey indicate that among current smokers ages 12–18, 60% reported that they would definitely be able to quit smoking if they wanted to and 28% said they probably would be able to quit (American Legacy Foundation, 2002).

While intriguing, data from research on genetic testing for disease susceptibility do not provide strong support for an effect of genetic risk communication on health protective behaviors (Marteau & Lerman, 2001). With regard to cigarette smoking, Lerman and colleagues (1997) conducted a clinical trial to determine whether feedback on genetic susceptibility to lung cancer would motivate smoking cessation in an adult population. The results showed that such information did have beneficial effects on risk perceptions and the perceived benefits of quitting smoking; however, there was no significant effect on smoking behavior. Whether communication of genetic risk for addiction to adolescents would have a significant impact on relevant attitudes and behavior is an open empirical question.

In summary, ongoing research is elucidating the determinants of tobacco use and dependence in youth. Although scientific advances in the genetics arena offer some promise, biology offers less than half the answer for those seeking to reduce tobacco use among youth, with social and environmental factors playing an equal or larger role. Thus, the expertise of multiple disciplines and methodological approaches is needed to meet the needs of the most vulnerable adolescents.

MEDIATING FACTORS

While adolescents in the United States are widely exposed to a spectrum of drugs of abuse, research suggests that adolescent substance abuse problems are due to multiple factors (Table 19.1). Most theories suggest that genetic, psychological, familial, and nonfamilial environmental factors are thought to interact in a complex way to determine an adverse or protective outcome. Thus, genes, temperament, attitudes and beliefs, family environment, peer affiliation, and social norms all mediate the relationship between the individual and a substance use disorder outcome. The developmental timing of these factors adds an additional level of complexity. The question of “nature or nurture” has been rendered moot, primarily by research conducted over the last 10 years. It is clear that both nature and nurture are involved, set against the backdrop of child development. Thus, there is no single cause of adolescent substance abuse, and any single prevention approach is unlikely to have broad universal success.

Table 19.1 Who Is at High Risk?

Children engaged in early alcohol or drug experimentation

Offspring of substance-dependent parents

Children with substance-abusing siblings

Children with conduct disturbances

Children with psychiatric disorders

Children with deviant and substance-abusing peers

Children temperamentally seeking high sensation

Children with impulse and self-control problems

Children under poor parental supervision

Children living in heavy drug-use neighborhoods

Children with school problems

Children with social skills deficits

Children of parents with poor parenting skills

Children who are victims of trauma, abuse, and neglect

The behavior genetic theory does help us to identify high-risk children for prevention interventions. Clearly, offspring of parents with substance abuse problems are themselves at significant risk for becoming substance abusers. We can't alter the effects of genes, but we can modify the environmental experiences of high-risk children. Interventions that improve parenting practices may be important, not only for instilling appropriate disciplinary practices in the parents of high-risk children but also for enhancing parental involvement and monitoring. Social skills training may keep high-risk children from being rejected by high-functioning children forced into deviant peer groups. Thus, the revolution in genetics may allow us to learn how to best change the environments of children at risk for adolescent substance abuse.

TYPES OF PREVENTION INTERVENTIONS AND MODEL PROGRAMS

Prevention programs are categorized according to the following recently adopted definitions based on the audience they are designed to reach (Mrazek & Haggerty, 1994).

Universal Intervention Programs

Universal intervention programs are designed to reach the general population, such as all students in a given school or school district, through media campaigns, for example. Broadly speaking, universal interventions represent the most widely utilized approach to drug abuse prevention. In a review of major findings of research on adolescent risk, Jamieson and Romer (2003) have recommended special focus on universal interventions, indicating that they have “great promise.” They specifically note that early and continuous universal interventions that encourage mature decision making and healthy choices among youth have considerable potential. From a universalist intervention perspective, public health problems and their solutions are inextricably a part of the community social system; solutions are essentially universal, with some types of universal interventions facilitating access to higher-risk groups within the community that may warrant more intensive intervention. Im plementation of these types of interventions is typically supported by local community partnerships or coalitions.

The largest group of universal programs is the in-school intervention, typified by the well-known original Drug Abuse Resistance Education (DARE), a school-based primary drug prevention curriculum designed for introduction during the last year of elementary education. DARE is the most widely disseminated school-based prevention curriculum in the United States. Despite its popularity, independent evaluations of DARE have failed to demonstrate its effectiveness (Clayton, Cattarello, & Johnstone, 1996; Lynam et al., 1999). Recently, an enhanced version of DARE has been developed and tested (DARE Plus). Additional components added to the original DARE curriculum include a peer-led parental involvement classroom program called “On the VERGE,” youth-led extracurricular activities, community adult action teams, and postcard mailings to parents. Evidence suggests that DARE Plus produced significant reductions in alcohol, tobacco, and polydrug use among boys; but had no effect on girls (Perry et al., 2003).

Other school-based universal programs provide more promising results for both boys and girls. For example, the Life Skills Training Program (Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995) emphasizes teaching of drug resistance skills, self-management skills, and general social skills in the junior high school classroom setting. The program has been shown to demonstrate significant reductions in drug experimentation among student participants.

Another important group of universal interventions are family focused. An example of this type of intervention that has been rigorously evaluated and found to be effective is the Strengthening Families Program: For Parents and Youth 10–14 (SFP 10–14; Kumpfer, Molgaard, & Spoth, 1996; Molgaard & Kumpfer, 1995). Implementation of the SFP 10–14 entails seven sessions occurring once a week for 7 weeks. The SFP 10–14 has separate sessions for parents and children that run concurrently for 1 hour and focus on skills building. During the second hour parents and children participate together in a joint hour-long family session, during which they practice the skills learned in their preceding, separate sessions. The family session affords the opportunity for higher-risk families and those with special needs to identify available services. In addition, the family session includes activities designed to encourage family cohesiveness and positive involvement of the child in family activities. For the parental sessions the essential content and key concepts of the program are also presented on videotape. Further details regarding the SFP 10–14 is provided in published reports (Spoth, Guyll, & Day, 2002; Spoth, Redmond, & Shin, 2000, 2001; Spoth, Reyes, Redmond, & Shin, 1999).

Yet another group includes interventions that combine school-based interventions with those engaging parents and sometimes other community institutions. An example of this type of expanded program is Project STAR (Pentz et al., 1989). This approach attempts to involve the entire community with a comprehensive school program, a mass media campaign, a parent program, a community organizing component, and health policy change component. Project STAR has been shown to be effective in terms of reductions in drug use behavior in high school for those youth that began the program in junior high school.

In addition to these interventions, there are universal interventions that have made use of mass media in a primary role, either in one community or, in the most interesting cases, nationwide, to address drug use. Below is a discussion in some detail of a universal intervention in the form of mass media campaigns.

Case Study: Media Drug Abuse Prevention Campaigns

Although the money committed to mass media–based campaign interventions is now substantial, evaluations of serious mass media–based interventions addressing drug use are few. One was a field experiment in Kentucky, a second was an evaluation of the Partnership for Drug-Free America (PDFA) campaign in its earlier phase, 1987–1990, along with some ancillary trend data. Another evaluation was one of the Office of National Drug Control Policy's campaign between 1999 and the present. In addition to these evaluations, there is a literature on mass media campaigns that addresses adolescent smoking.

The Kentucky Intervention

The research group at the University of Kentucky (Donohew, Lorch, & Palmgreen, 1991) has a long history of anti-drug communication research based in the core construct of “sensation seeking.” They argue that this personality construct accounts for a substantially increased risk of drug use among youth, and thus would provide a basis for the development of a mass-media intervention. This work culminated in their development of a two-city test of a televised anti-marijuana campaign in 1997 and 1998. The project was an interrupted time series following youth in grades 7 through 10 in Fayette County (Lexington), Kentucky, and Knox County (Knoxville), Tennessee, for 32 months. The televised ads first ran for 4 months in Lexington, 8 months into the time series, and 1 year later for 4 months in both Lexington and in Knoxville. The campaign was developed so as to appeal particularly to high sensation–seeking youth. The ads were designed to have high sensation value; they were pretested with these youth; and they were shown in the context of high–sensation value television programs preferred by these youth. During a campaign period, enough ad time was purchased or donated so that 70% of the target audience should have seen ads three times per week.

The reported results of the evaluation were positive. Self-reported 30-day use of marijuana among high sensation–seeking youth declined (or climbed less than would have been expected) during all three campaign periods, and not during other periods. Strikingly, few youth seeking low sensation reported use of marijuana, regardless of the presence or absence of the campaign.

The Partnership for a Drug-Free America

The Partnership has been operating a mass media campaign since mid-1987. It describes itself as “a non-profit coalition of professionals from the communications industry.” Through its national drug-education advertising campaign and other forms of media communication, the Partnership seeks to help kids and teens reject substance abuse by influencing attitudes through persuasive information.

One evaluation approach notes correlated secular trends: the first 5 years of the PDFA's existence, between 1987 and 1992, match a period of substantial decline in youth reports of drug use. That is the period when PDFA had its heaviest presence in the advertising marketplace. After 1992, when it became less successful in generating donated advertising time, particularly on television, the decline in youth reports of use was reversed, and drug use continued to climb through 1998. In a similar analysis focused on inhalant use, Johnston, O'Malley, and Bachman (2002a) found that the PDFA's initiation of strong anti-inhalants advertising in 1996 forecast a period of decline in inhalant use among youth. However, data drawn from secular trends are inevitably open to other interpretations, recognizing that there are many exogenous influences on such trends. Indeed, the secular trends in marijuana use, for example, establish that the start of the decline in such use preceded the introduction of the PDFA campaign in 1987. This is evident in the time trend data from the Monitoring the Future (MTF) surveys for 12th graders reporting annual use of marijuana. The downward trend was fairly constant from 1983 onward, 4 years prior to initiation of the PDFA campaign. Although it is possible that the decline might have stalled absent the initiation of the campaign, that is not the only possible interpretation of the pattern (Johnston, O'Malley, & Bachman, 2003a).

The National Youth Anti-Drug Media Campaign

The National Youth Anti-Drug Media Campaign is the direct inheritor of the PDFA campaign. It came out of the PDFA's recognition that it was no longer able to generate the donated media time it had previously received, and reflected intensive lobbying of Congress and the administration to make up the deficit. The long decline in marijuana use had ended in 1992, and had climbed substantially by 1997, also raising congressional concern. The PDFA envisioned the new campaign operating with the government buying media time for the ads generated by PDFA, but the eventual legislation shifted control of the Campaign to the White House Office of National Drug Control Policy (ONDCP) and added other provisions. While most money was allocated to the purchase of time for advertising largely produced under the PDFA mechanism, the overall message strategy was designed outside of PDFA, and the advertising was to be complemented by public relations efforts in-cluding community outreach and institutional partnerships. Youth were addressed directly, but the campaign spent its resources equally on parent-focused messages, particularly encouraging parenting skills and monitoring of youth behavior.

The Congress funded an independent evaluation through National Institute on Drug Abuse (NIDA) which contracted with Westat and the Annenberg School for Communication at the University of Pennsylvania. The evaluation is ongoing, with the most recent report covering the first 2.5 years of the fully implemented campaign (Hornik et al., 2002). Pertinent results thus far are as follows.

  • Most parents and youth in the surveys recalled exposure to Campaign anti-drug messages. About 70 percent of both groups reported exposure to one or more messages through all media channels every week. The average (median) youth recalled seeing one television ad per week. In 2000 and the first half of 2001, less than 25 percent of parents recalled seeing a television ad every week; this increased to 40 percent in the second half of 2001 and to 50 percent in the first half of 2002.

  • There is evidence consistent with a favorable Campaign effect on some parent outcomes. Overall, there are favorable changes in three out of five parent belief and behavior outcome measures, including talking about drugs with children and monitoring of children. Moreover, parents who reported more exposure to Campaign messages scored better on four out of five outcomes after statistical controls were applied to adjust for the possible influence of other explanatory factors. In addition, parents who had more exposure the first time they were measured were more likely to talk with their children and do fun activities with their children subsequently. However, there was little evidence for Campaign effects on parents' monitoring behavior. That has been the focus of the parent Campaign and the one parent behavior most associated with youth nonuse of marijuana. In addition, there is no evidence for favorable indirect effects on youth behavior as a result of parent exposure to the Campaign.

  • There is also little evidence of favorable direct Campaign effects on youth. There is no statistically significant decline in marijuana use to date in the surveys undertaken for the evaluation (although the MTF study suggested that there was a small but significant decline in marijuana use between 2001 and 2002 at the 10th-grade level; Johnston, O'Malley, & Bachman, 2003a). However, there were no improvements in surveyed beliefs and attitudes about marijuana use between 2000 and the first half of 2002. Regardless of whether the trends were stable or showing a slight decline, there is no basis for attributing any youth changes to the Campaign specifically. Also, and of most concern, there is evidence for an unfavorable delayed effect of Campaign exposure from September 1999 through June 2001 on intentions to use marijuana and on other beliefs expressed 12 to 18 months subsequently.

Several hypotheses have been suggested to explain why a campaign might produce a boomerang effect. One comes from reactance theory (Brehm, 1966; Brehm & Brehm, 1981), an argument that youth react against adult threats to their freedom by feeling pressure to re-establish that freedom, including some pressure to engage in the forbidden behavior. The Campaign might represent such a threat. Another theory argues that the heavy dose of anti-drug messages carries a meta-message, the idea that many youth must be using drugs if there is so much attention being paid to them. Indeed, for this hypothesis there is some consistent evidence: youth more exposed to the campaign advertising are more likely to progress subsequently to a belief that most other kids are using marijuana, and that belief predicts subsequent initiation of marijuana use. Other hypotheses include the idea that ads that contain relatively weak arguments serve to stimulate strong counterarguments (J., 2003), or the idea that for some youth, the ads provide novel information and thus provoke curiosity about drugs.

Selective Intervention Programs

Selective intervention programs are designed to target groups at risk as subsets of the general population, such as children of drug addicts or children with school problems.

The Strengthening Families Program (Kumpfer & Alvardo, 1995) and the Focus on Families Program (Catalano, Gainey, Fleming, Haggerty, & Johnson, 1999; Catalano, Haggerty, Gainey, & Hoppe, 1997) represent examples of selective interventions for children with drug-abusing parents, with slightly different approaches. Strengthening Families contains three elements: a parent training component, a child skills training component, and a family skills training component. The goal of the parent training component is to reduce parental substance abuse and improve parenting skills. The goal of the child skills training component is to decrease the child's negative and socially unacceptable behavior. The goal of the family skills training component is to improve the family environment. Evaluations of efficacy so far have found short-term benefits for this intervention; longer-term studies have not been done.

Focus on Families is for parents receiving methadone maintenance. Here parents are taught skills for relapse prevention and coping to help improve their treatment outcomes, as well as family management and parenting skills. Preliminary data suggest that this program improves treatment outcomes of parents and enhances their parenting skills.

Indicated Intervention Programs

Indicated intervention programs are those designed for groups already experimenting with drugs or engaging in other risky practices. To a great extent, indicated programs traverse the fine line between prevention and treatment interventions. The Reconnecting Youth Program (Eggert, Thompson, Herting, & Nicholas, 1995; Eggert, Thompson, Herting, Nicholas, & Dicker, 1994) is a prime example. This program is for adolescents in grades 9 to 12 who show signs of poor school achievement and the potential to drop out. The program teaches skills to build resiliency toward risk factors and to moderate early signs of drug abuse. It consists of several components, such as a personal growth class designed to enhance self-esteem, decision making, personal control, and interpersonal communications; a social activities and school bonding program to establish drug-free peer relationships; and a school system crisis response plan to address suicide prevention. Evaluations of this intervention have documented only short-term benefits, with long-term studies yet to be done.

Multilevel Intervention Programs

Multilevel intervention programs are typically ambitious combinations of the above intervention models. They include universal, selected, and indicated strategies gauged to the needs of the adolescent.

The Adolescent Transitions Program (Dishion & Kavanagh, 2000) is an example of a multilevel intervention designed to address the needs of families of young adolescents that present with a range of problem behaviors and diverse developmental histories. This ambitious program incorporates universal, selective, and indicated prevention components. The universal prevention intervention is in the form of a school-based family resource room to establish a venue for exchange between school professionals and fam ilies. The selective intervention is in the form of a family check-up that offers family assessment and support, and the motivation to change behaviors. The indicated intervention provides a menu of services that includes a brief family intervention, school monitoring system, parent groups, behavioral family therapy, and case management services.

SUMMARIES AND REVIEWS OF MODEL PREVENTIVE INTERVENTIONS

Over the past decade numerous efforts have been undertaken to identify and disseminate descriptive information about model preventive interventions. In the family-focused prevention area alone, for instance, at least 11 of these model intervention reviews have gained some currency (Metzler, Biglan, Rusby, & Sprague, 2001). Reviews of model preventive interventions typically include descriptions of selection criteria or rules of evidence applied and summaries of the intervention review process. Many also delineate salient characteristics of the types of programs that have proven to be effective. A major issue for the field is the variability in the rules of evidence and intervention selection criteria, with the level of scientific rigor applied ranging considerably.

Frequently, model interventions are classified by the level of supportive evidence for the intervention (e.g., exemplary or promising). Most reviews of interventions consider the level of evidence for a particular intervention; some, however, create categories of interventions and critically evaluate the evidence only for specified types of interventions. Table 19.2 summarizes selected reviews of particular evidence-based interventions; it does not include reviews of types of programs. Rather, these are included in the following summary of meta-analysis and reviews of outcome studies of interventions from the relevant literature. Although some of the reviews are focused exclusively on interventions designed to prevent substance use or abuse among youth, many include interventions that target other youth problem behaviors as well. All of the reviews selected for inclusion in Table 19.2 have critically evaluated at least some substance-related preventive interventions described in published reports. Included in Table 19.2 is an especially instructive “review of reviews” of particular family-focused preventive interventions (Meltzer et al., 2002).

Table 19.2 Reviews of Particular Evidence-Based Interventions

Reference

Level of Intervention

Summary

Alvarado, Kendall, Beesley, & Lee-Cavaness, 2000

Family

This review entails “Two page summaries of family-focused programs which have been proven to be effective.The programs in this booklet are divided into categories based upon the degree, quality and outcomes of research associated with them” (p. vi). “Numerous criteria were utilized by the review committee to rate and categorize programs. The criteria included: theory, fidelity of the interventions, sampling strategy and implementation, attrition, measures, data collection, missing data, analysis, replications, dissemination capability, cultural and age appropriateness, integrity and program utility. Each program was rated independently by reviewers, discussed and a final determination made regarding the appropriate category” (p. vii).

Catalano, Berglund, Ryan, Lonczak, & Hawkins, 2002

Multiple

This review “Describes the findings from evaluations of positive youth development programs. The chapter highlights 25 well-evaluated programs and their results. Elements of the programs are described, including positive youth development constructs, social domains, and strategies.” (http://www.journals.apa.org/prevention/volume5/pre0050015a.html)

Center for the Study and Prevention of Violence, 2003

Multiple

The center “Has identified 11 prevention and intervention programs that meet a strict scientific standard of program effectiveness.The 11 model programs, called Blueprints, have been effective in reducing adolescent violent crime, aggression, delinquency, and substance abuse. Another 21 programs have been identified as promising programs.” (http://www.colorado.edu/cspv/blueprints/)

Developmental Research and Programs, 2000

Multiple

Communities that Care (CTC) is an integrated approach to positive youth development and the prevention of problem behaviors including substance abuse, academic failure, unplanned pregnancy, school dropout, and violence. This program is based on prevention science—social development theory—which aims to identify and reduce risk factors and promote protective factors in the development of problem behaviors among young people. (http://www.channing-bete.com/positiveyouth)

Drug Strategies, 1999

School

This assessment “is based on careful review of curriculum materials and other information provided by curriculum developers and distributors as well as evaluation reports on 14 curricula.Extensive research during the past two decades points to certain key elements of successful prevention curriculaassesses the extent to which curricula address these key areas” (p. 1).

Eccles & Gootman, 2002

Community

“We considered reviews that included both programs for youth with a primary focus on prevention and programs explicitly focused on a youth development framework.Programs based on clinical theories of behavior change and sound instructional practices are effective at both reducing problem behaviors and increasing a wide range of social and emotional competencies. In addition, interventions in the field of mental health promotion use high evaluation standards. All evaluations included in both reviews used both control group comparisons, and the majority used random assignment. The high level of evaluation rigor obtained was understandably facilitated by the short-term nature of the programs, the integration of these programs into the school day, and the fact that program participation was more likely to be seen by participants as required rather than voluntary” (pp. 148, 172).

Greenberg, Domitrovich, & Bumbarger, 2000

Multiple

“The goals of this report were toidentify universal, selective and indicated programs that reduce symptoms of both externalizing and internalizing disorders; summarize the state-of-the art programs in the prevention of mental disorders in school-age children; identify elements that contribute to program success; and provide suggestions to improve the quality of program development and evaluation.” (http://www.prevention.psu.edu/resources.html)

The scope of interest for this review included prevention programs for children ages 5 to 18 that produce improvements in specific psychological symptoms or in factors directly associated with increased risk for child mental disorders. Programs were excluded if they produced outcomes solely related to substance abuse, sexuality or health promotion or positive youth development.

Hansen, 1992

School

“Substance use prevention studies published between 1980 and 1990 are reviewed for content, methodology and behavioral outcomes.Studies were classified based on the inclusion of 12 content areas: Information, Decision-Making, Pledges, Values Clarification, Goal Setting, Stress Management, Self-Esteem, Resistance Skills Training, Life Skills Training, Norm Setting, Assistance and Alternatives. Comprehensive and Social Influence programs are found to be most successful in preventing the onset of substance use” (p. 403).

Olds, Robinson, Song, Little, & Hill, 1999

Family

This study is a review of research that tested universal, selected, or indicated interventions that took place between the prenatal period and a child's fifth year (0–5) and examined outcomes indicative of either child behavioral adjustment problems or major parent or family risk factors (e.g., maternal mental health and use of substance; relationship disturbance).

Promising Practices, 2001

Multiple

“PPN [Promising Practices Network] has organized information on effective programs under six broad result areas that are associated with the well-being of children, youth, and families. For each of these results areas, one or more specific benchmarks have been identified.PPN provides a summary of each program that identifies key information about its effectiveness.We've included programs that meet a minimum level of evidence and are labeled as follows: (1) Proven—at least one credible, scientifically rigorous study that shows the program improves at least one benchmark; Promising—at least some direct evidence that the program improves outcomes for children and families.” (http://www.promisingpractices.net)

Roth, Brooks-Gunn, Murray, & Foster, 1998

Multiple

“We evaluate the usefulness of the youth development framework based on 15 program evaluations. The results of the evaluations are discussed and 3 general themes emerge” (p. 423).

SAMHSA Model Programs, 2003

Multiple

Programs are evaluated according to 18 methodological criteria, three appropriateness criteria, and program descriptors for evaluating general substance abuse and treatment programs. “Individual scores from members of each reviewer team are compiled, together with their narrative descriptions of the review program's strengths, weaknesses, and major components and outcome findings. Summary scores from two parameters, Integrity and Utility, are then used to rank programs respectively on the scientific rigor of their evaluation and the practicality of their findings.” (http://modelprograms.samhsa.gov/pdfs/compmatrix.pdf)

Strengthening America's Families, 1999

Multiple

This Web site describes effective family programs for the prevention of delinquency. Programs for the prevention of delinquency and other negative outcomes are described and rated against a set of criteria as “Exemplary,” “Model,” or “Promising.” The Web site also contains a literature review and an organizational matrix of programs, arranged by type of prevention program (universal, selected, indicated). Available on-line at: http://www.strengtheningfamilies.org/html/model programs/mfp pg1.html

U.S. Department of Education, 2001

School

“This publication provides descriptions of the 9 exemplary and 33 promising programs selected by the 15-member Expert Panel for Safe, Disciplined, and Drug-Free Schools in 2001.The task was to develop and oversee a process for identifying and designating as promising and exemplary programs that promote safe, disciplined, and drug-free schools. The seven criteria are: (1) The program reports relevant evidence of efficacy/effectiveness based on a methodologically sound evaluation; (2) The program's goals with respect to changing behavior and/or risk and protective factors are clear and appropriate for the intended population and setting; (3) The rationale underlying the program is clearly stated, and the program's content and processes are aligned with its goals; (4) The program's content takes into consideration the characteristics of the intended population and setting (e.g., developmental stage, motivational status, language, disabilities, culture) and the needs implied by these characteristics; (5) The program implementation process effectively engages the intended population; (6) The application describes how the program is integrated into schools' educational missions; (7) The program provides necessary information and guidance for replication in other appropriate settings” (pp. 1–2).

SAMHSA, Substance Abuse and Mental Health Administration.

THE FUTURE OF YOUTH PREVENTION PROGRAMS: NEW DIRECTIONS

Recently, prevention professionals have broadened the target of their interventions, extending beyond substance abuse to globally address the quality of youth development. Advocates of positive youth development approaches emphasize that efforts to address public health concerns by preventing youth problem behaviors must be pursued in concert with youth-related health promotion goals. The need to integrate prevention and youth-related health promotion—or positive youth development—has emerged as a consequence of the observation that problem-free youth are not necessarily fully prepared youth (Pittman, Irby, & Ferber, 2000). In keeping with this concept, several scholars (Eccles & Gootman, 2002; Flay, 2002; Lerner, 2001; Roth & Brooks-Gunn, 2002; Villarruel, Perkins, Bordon, & Keith, 2003) have cogently argued for the need for strategies and interventions that prepare young people to fully participate in school and career, by reducing the level of harmful or risk behaviors and building “external” developmental assets (e.g., support from parents, peers, teachers) along with “internal” assets (e.g., social competencies—see Scales, Benson, Leffert, & Blyth, 2000).

Community-based intervention researchers have underscored how difficult it is to accomplish substantial behavior change in large populations (e.g., Holder, 2002), in part because of natural tensions between researchers and community-based practitioners (Greenberg & Spoth, in press; Spoth & Greenberg et al., in press; Price & Behrens, 2003; Wandersman, 2003). This conclusion is consistent with earlier admonitions about ways in which prevailing economic, political, and social forces can perpetuate unhealthy behaviors such as problem drinking (Giesbrecht, Krempulec, & West, 1993). Many researchers agree that the key to address ing this challenge lies in universal, community-based innovations (e.g., Holder, 2001).

Holder (2001, 2002) notes that there have been two different approaches to addressing substance-related public health goals—namely, the catchment and community-system approaches. In the catchment approach to prevention of substance-related problems, a community is viewed as a collection of target groups with adverse behaviors and correlated risks. Operationally this involves locating persons at risk, identifying their risk factors, and implementing interventions to reduce risk factors, often entailing education-based programs. Notably, there is little attention to social dynamics or organiza-tional-and systems-level factors influencing individual target group behaviors. Consistent with the emphasis on environmental influences and potential supports for youth development is the focus of the community-systems approach on the community at large, defined as a set of persons “engaged in shared, social, cultural, political, and economic processes” (Holder, 2002, p. 906). Thus a wide range of problems is collectively considered and the focus is on interventions that address a variety of aspects of the shared behavioral environment in a community. This focus is consistent with the idea of a comprehensive youth strategy recommended by Jamieson and Romer (2003) and others (e.g., Flay, 2002; Roth & Brooks-Gunn, 2002).

A recurring theme in the literature on community partnerships, particularly that concerning diffusion of evidence-based interventions, is the need for community intervention capacity-building, as a way to sustain quality imple-mentation of preventive and developmental competency-building interventions (e.g., Altman, 1995; Lerner, 1995; Morrisey et al., 1997). In this case, capacity building can be defined as efforts designed to enhance and coordinate human, technical and scientific, financial, and other organizational resources directed toward quality implementation of evidence-based, developmentally oriented, preventive interventions for youth (see Spoth et al., 2004). A lack of capacity for sustained intervention implementation is frequently cited as a primary reason for failures in community-based dissemination of interventions (e.g., Arthur, Ayers, Graham, & Hawkins, 2003; Feinberg, Greenberg, Osgood, Anderson, & Babinski, 2002; Goodman, 2000). This is particularly true in the case of school-based interventions (Gottfredson & Wilson, 2003; Hallfors, 2001). Especially problematic is the fact that efficacious school-based interventions are frequently unable to survive the withdrawal of grant funding (Adelman & Taylor, 2003).

FUTURE CHALLENGES

It is fitting to close this chapter on prevention by highlighting the challenge of the necessary bridge building for an improved youth development strategy. Just as there must be a construction plan for building a viable bridge across a chasm or gorge, requiring careful integration of input from a diverse group of designers, planning for a comprehensive strategy to foster positive youth development and prevent youth substance-related problems necessitates a sustained, well-organized effort, with input from a range of community interventionists, scientists, and policymakers at the state and federal levels. One potential contribution to this larger planning effort is a design for universities and communities to partner together to foster a higher prevalence of capable and problem-free youth. However, the wide range of tasks for those involved in community–university partnerships, the many barriers to task accomplishment, and the limited resources available highlight the challenges to design implementation that lie ahead. The single most salient feature of this particular challenge is the apparent gap between necessary human, technical and scientific, and funding resources on the one hand and the limited resource availability on the other. Nonetheless, the salience of the resource gap underscores the potential benefits of efficient and effective capacity building, particularly that which is based in existing community, state, and national infrastructures for coordinated activities supportive of youth.