1994 VOL 5 NO 2
Copyright© IJDP Ltd.
PREVENTION PROGRAMMES FOR ADOLESCENTS IN THE USA
Elaine Norman and Sandra Turner review the theories of human behaviour which have served as the foundation for prevention strategies used in the USA, the programme models based on them, and the research literature that evaluated the effectiveness of each of the prevention strategies.
SUBSTANCE ABUSE THEORIES
The theoretical foundations of the most effective prevention approaches in the last 20 years include the following five theories of personality development and behavioural motivation:
- problem behaviour theory,
- social learning theory,
- cognitive and social inoculation theory,
- stage theory,
- biopsychosocial theory.
Problem behaviour theory
Problem behaviour theory, developed by Jessor and Sessor ( 1977 ), contends that early dysfunction. behaviour is associated with drug misuse in adolescence. Youngsters who are most vulnerable to substance misuse are those who are alienated from the values and norms of their families, schools and communities; have a high tolerance for deviance; low religiosity; resistance to traditional authority; are sensation seeking; do not show concern for their own safety; do not do well in school; and befriend drug using peers (Hawkins et al., 1985, 1992).
In addition, problem behaviour theory emphasises the importance of youngsters' perceptions of parental or peer attitudes and behaviour as determinants of their own behaviour. Social learning theory, on the other hand, stresses the actual behaviour of parents and peers as being very influential.
Social learning theory
Social learning theory, developed by Bandura ( 1977), envisions social behaviour as acquired through direct conditioning, or through modelling of others' behaviour. The theory sees human behaviour as the product of continuous reciprocal interaction between cognitive, behavioural and environmental factors.
Behaviour is shaped through the positive reinforcement of reward and the negative reinforcement of punishment. It is weakened by aversive stimuli and by loss of reward (Kim,1989). The theory posits that the interaction of inner forces and environmental stimuli determines how people will behave. One's behaviour is learned and moulded by watching others' behaviour and by integrating how others respond (Rhodes and jason,1987). Substance use and abuse are socially learned behaviours. Some children will learn to use alcohol and other drugs to help cope with stress if their parents, peers or other important people in their environment do so.
A notable feature of social learning theory is the importance it places on self regulating capacities. People have the ability to anticipate the consequences of their own behaviours, as well as the reactions of others to those behaviours. Youngsters learn from observing others' behaviour, as well as from direct experience.
Cognitive and social inoculation theory
Cognitive and social inoculation theory maintains that one can be 'inoculated' against submitting to negative peer and family pressure to use alcohol and other drugs through training in protective life skills (McGuire,1968; Evans et al.,1981). Prevention programmes based on this theory offer 'pre-treatments' to build up a resistance or an 'immunity' to substance using behaviour. Many of the conflicting ideas and opinions about substances to which adolescents are likely to be exposed are introduced to them at a young age, and 'antidotes' or positive resolutions are put forward, so as to prepare or 'immunise' these youngsters against future pressures. 'Booster' sessions given at future intervals reinforce the initial 'immunisation' work (Botvin andWills,1985) . Youngsters are taught skills to resist social influences and pressures to smoke, drink or use other drugs. They are encouraged to make a public commitment, such as announcing in a school assembly that they have decided to stay drug free. A public statement about non-use, which also demonstrates a strong commitment to school and community, can be very powerful (Macguire,1968).
Stage theory developed by Kandel (1980) proposes that programmes should be shaped to address the particular developmental issues that adolescents are like
ly to be dealing with at that specific time. Boys and girls both face many adolescent tasks: establishing a sense of self or identity, developing an ability to form intimate relationships, separating from one's family, developing an ability to function differentially (in school, work and social relationships), and choosing a career. However, they face these tasks at different times in their lives and are under different kinds of social and physiological pressures. Boys tend to be more physically and psychologically vulnerable in the first decade of life, whereas girls are more vulnerable in the second decade . Boys are likely to deal with issues of separation earlier than girls do, whereas girls deal with issues of intimacy at younger ages than boys do ( Brown etal.,1992).
Adolescents of both genders often seek relief from boredom and loneliness (Kandel,1980). Cigarette, alcohol and other drugs can be very effective mood changers, and can appear to ease boredom, end the difficulty of socialising with peers, of separating from family and of finding answers to questions about identity. Stage theory directs the timing of specific prevention strategies so as to address these issues as they arise.
Biopsychosocial theory, sometimes called social ecology theory, focuses on the interaction between people and their internal and external environments (Hawkins andWeiss,1985; Kumpfer and DeMarsh, 1985; Wills and Shiffman,1985). Programmes modelled on this theory concentrate on the adolescent's relationship with family and school. The theory posits that youngsters who are given opportunities to participate in family and school decision-making processes, and receive positive feedback about their participation, are likely to develop positive bonds to their families and their schools, and possibly to the community at large. Programmes based on this theory work with parents and teachers toward the goals of establishing clear rules and expectations for youngsters, firm boundaries, and strong support and rewards for preferred, positive behaviours by the youngsters (Hawkins and Weiss, 1985; Kumpfer and Turner, 1991 ).
In summary, problem behaviour theory forms a basis for predicting which adolescents are likely to be at high risk for substance misuse . It could be considered a theory of vulnerability rather than behaviour. Stage theory emphasises the timing of prevention and has inspired the initiation of programming for younger and younger age groups. Social learning theory with its emphasis on modelling, cognitive and social inoculation theory, with their emphasis on the learned inhibition of unwanted behaviour, and biopsychosocial theory, with its focus on the importance of family, school and community, together form the foundation of the most successful prevention programming of the 1980s.
PREVENTION PROGRAMME MODELS
Almost all adolescent substance abuse prevention programmes implemented in the USA in the last 20 years can be categorised into at least one of the following four models(Silverman,1988):
- 1. The information-only model. 2. The alternatives model.
- 3. The affective education/social competency model.
- 4. The social environmental model.
The first three were early efforts, not firmly based in theory. The fourth, the social environmental model, is rooted in the theoretical frameworks discussed in the first part of this paper. Accumulating research literature seems to indicate that this fourth model yields positive prevention results. We will discuss each of the four models in turn.
The information-only model
This model uses classrooms and small theatres to educate adolescents about drugs. Based on the idea that youngsters use substances because they simply do not know enough about their dangers and adverse consequences, this model attempts to increase knowledge, which in turn is expected to change attitudes, and ultimately to change behaviour.
Information offered in such programmes includes data on things such as the properties of, and reactions to, various substances; the methods of use; and the immediate as well as long-term social and health consequences of use. A small number of such programmes used scare tactics, dramatising the negative aspects of use, exaggerating harmful effects and focusing only on adverse outcomes.
Research evaluation of information-only programmes has demonstrated negligible and sometimes counterproductive results (Moskowitz et al.,1984b). The young people tend to disbelieve the exaggerated negative claims that are made. This, in turn, tends to undermine the youngsters' confidence in the programme's teachers. Curiosity is sometimes aroused by such programmes, increasing the likelihood of initial experimentation (Hawkins et al.,1985). Most importantly, this model is based on the questionable assumption that a few hours of instruction about the negative aspects of substance use can erase the many years of learning about the acceptability of cigarettes, alcohol and marijuana from parents, peers and the media(Weisheit,1983).
The research evidence does not support the claim that information only programmes prevent or curtail substance use. It does support the impact of such programmes on knowledge acquisition (Tobler,1986; Hansen et al,1988a). Knowledge components have therefore been integrated into other prevention mod els, especially information about the short-term immediate social and health consequences of use.
The alternatives model
This model attempts to involve adolescents in activities that are not related to substance use, and that keep the youngsters interested, busy and creative . N on- use of drugs is not specifically focused upon in these activities. It is, however, assumed that involvement in alternative activities, such as recreational programmes and special projects, will relieve boredom, increase self efficacy, cement community bonding and thereby decrease any tendency towards use of sub stances.
A large share of prevention resources is invested in alternatives programmes, but there is very little published evidence that they effectively deter substance use (Kim,1981; Moskowitz et al.,1983,1984a; Cook et al.,1984; Stein et al.,1984). In fact, there is evidence that participation in activities of a social nature such as entertainment and sports, which often have substance users present, is associated with increased, rather than decreased, use (Swisher andHu,1993).
Decreased use has been shown to be associated with individual and pro-social pursuits such as hobbies and religious activities. One study suggested that 'high risk' young people could benefit from alternatives programmes that included skills acquisition components and a great many hours of programming (Tobler,19865. However, professionals in the field, influenced by the many negative research evaluations, have almost entirely discounted this model. Schaps (1986) and his colleagues conclude that:
- Alternatives programs as currently conceived and implemented are likely to be ineffective as
- prevention measures.
The affective education/social competency model
This model, otherwise known as the individual deficiency model or the social competency model, assumes that substance use is associated with low self esteem, inadequate decision-making, problem-solving or communication skills and inappropriate values. Adolescents who are helped to develop those characteristics will be less likely to use drugs. Activities built into programmes based on this model include: stress management and reduction techniques, self-concept building, value inventory development, problem solving and decision-making training, assertiveness and communication enhancement techniques. Broad personal and social competency and coping skills are addressed, but non use of substances messages is not specifically included ( Hansen,1988) .
Research evaluations of affective education/social competency programmes have not supported thtir effectiveness as deterrents of substance use. Of 60 programmes of this type studied by Schaps et al. (1981), 37 showed no effect on substance use,20 showed a small effect and only three a noteworthy effect.
The three programme models discussed so far have all shown little or no power to influence adolescent substance use. The fourth model we are about to discuss, the social environmental model, has had some promising outcomes.
The social environmental model
This model, based on social learning theory and often called by that name, has been shown rather consistently to reduce substance use among adolescents. The model depends heavily on the assumption that overt and subliminal pressures from peers, family and media are the greatest influencers of substance use. Strategies are developed and taught to youngsters which help them to be aware of those pressures and to have scripts ready to resist them. Programmes based on this model have had modest but encouraging results, mainly for smoking, but also for alcohol and marijuana.
Programmes inspired by this model feature most of the following components:
- 1. Training adolescents to identify and resist the
- pressures to use substances which come from media, peers and family members:
- (a) youngsters are taught to identify the forms peer pressure takes, to do critical analysis of messages from the media. and to be aware of user parent messages;
- (b) youngsters develop, role-play and repeat strategies to resist pressures to use drugs. Feedback and other reinforcement techniques are used to help participants become competent in executing these resistance strategies. A package of refusal skills becomes part o each participant's behavioural repertoire.
- 2. Education to reinforce non-use norms is under
- (a) the reasons adolescents use substances are examined;
- (b) the actual, as compared to the imagined, prevalence and acceptability of substance use are explored;
- (c) non-use norms and expectations are mutually developed. Participants are encouraged to make non-use commitment statements publicly.
A large number of, but not all, programmes add other components in addition to the ones noted above, including:
- 3. Information about substances, particularly their short-term personal consequences such as smelling badly, having an accident, and acting out of control.
- 4. Activities that address decision-making and problem-solving skills development, and stress management and self worth enhancement are also included in some programmes (Botvin et al., 1982, 1983; Pentz et al., 1989a; Ellickson and Bell,1990).
The social environmental model has been implemented primarily as a school-based intervention, but it also has been included in connection with larger community-based programmes (Pentz et al., 1989a,b,c; Perry et al.,1989). Here the primary intent is the persistent and consistent communication of a non-use message to youngsters from parents, school personnel, local business and community leaders.
The school-based social environmental model programmes that have been researched have almost always had sixth or seventh graders as participants. Those years are seen as particularly vulnerable for North American youngsters because they span a transition year during which most move from grade school to junior high school.
White middle class youth who have a low risk for substance use have made up the bulk of programme participants. A number of successful efforts have focused on native American Indian youngsters, and other minority populations (Gilchrist et al.,1987; Schinke et al.,1988a; Ellickson and Bell,1990) . One researcher, in particular, found resistance training to be successful, whereas affective education proved to be unsuccessful, with a sample that contained three quarters minority students (Hansen et al.,1988c).
Numerous studies of the ability of the social environmental model to prevent substance misuse among adolescents have shown the model to be very promising. Table l lists over 20 programme evaluations published in the 1980s and early 1990s. They cover the entire USA and represent nearly all the research evaluations of successful social environmental model programmes published in the last 12 years.
The record is best for tobacco, and more limited but encouraging for alcohol. Four programmes focused exclusively on alcohol have had positive results (Botvin et al.,1984; Wodarski,1987; Dielman et al., 1989; Perry et al., 1989). Alcohol use reductions were also found in several evaluations of programmes focused on multiple substances (Gilchrist et al.,1987;Hansenetal.,1988b;Schinkeetal.,1988b; Pentz et al., 1989a; Botvin et al., 1990). Pentz's (1983) programme in Tennessee actually had better 6-month follow-up results for alcohol non-use than for cigarette non-use. There have been some studies, however, which indicate this model is not particularly useful for preventing alcohol use. Hansen and his colleagues (1988a) in California found tobacco, but not alcohol, reductions as a result of their programme. Ellickson and Bell's (1990) programme in California and Oregon, which also targeted multiple substances, was effective with the long-term reduction of cigarette and marijuana use, but had only short-term effects on alcohol use. For all substances, erosion of programme effects over time ( e.g. within 6 months to 2 years of programme conclusion) is very likely. Booster sessions in subsequent years are frequently added to reinforce the original programme goals.
TABLE 1: Social envoronmental programmes with positive outcomes
|PROGRAMMES ADDRESSING SMOKING
|Botvin and Eng (1982)
|Botvin et al. (1983)
|Biglan et al (1987)
|Evans et al (1981)
|Flay et al (1985, 1989, 1990)
|Luepker et al (1983)
|Perry et al (1989)
|McAlister et al (1980)
|Pentz et al (1989)
|Perry et al (1983)
|Schinke et al (1988a)
|PROGRAMMES ADDRESSING ALCOHOL
|Botvin et al (1984)
|Dielman et al (1989)
|Perry et al (1989)
|PROGRAMMES ADDRESSING MULTIPLE SUBSTANCES
|Botvin et al (1990)
|Ellickson and Bell (1990)
||California and Oregon
|Englander-Golden et al (1986)
|Gilchrist et al (1987)
|Hansen et al 1988a,b)
|Pentz et al (1989a, 1989b)
|Schinke et al (1988b)
LARGER SYSTEM INVOLVEMENT (FAMILY, SCHOOL AND COMMUNITY)
Along with working with the individual adolescents, prevention programmes have in the last decade moved towards working with the family, school and community as well. Some programmes have attempted to enhance family functioning by using family training programmes to strengthen the family's role in socialising the child. These programmes stress the importance of communication between parent and child, offering help with this and with family problem solving techniques. Parents are encouraged to use less judging, blaming and preaching, and more encouragement, high expectations and affection (Klein and Swisher,1983; Szapocznik et al., 1989). Schaps and his colleagues (1981), in their review of 127 prevention programmes, found that such family relationship-building work was one of the most effective in preventing substance misuse among youngsters. Even substance-abusing parents have been coached and assisted in developing more effective parenting styles (DeMarsh and Kumpfer,1985) .
A positive school climate, which involves students and allows them to feel heard and respected by teachers and administrators, will result in increased bonding to the school and will help deter students from getting involved with antisocial peers. Kumpfer and Eurner (1990) contend that this, in turn, has the potential to deter involvement with substances.
Several large comprehensive community prevention programmes have been undertaken in the USA. Project Star in Missouri and Indianapolis (Pentz et al, 1989a,b; Wohnson et al., 1990), and the Minnesota Heart Health Program (Perry et al.,1989) emphasise conveying community-wide non-use messages to their youngsters. The programmes include development and communication of positive community norms, school-based resistance skills training for the youngsters, parent involvement in school policy development and the training of parents in family communication skills. The package has proved to be an effective prevention endeavor.
Although much has been learned from the programmes and research of the 1980s, we still have much to find out. We know that the social environmental model is effective in preventing substance misuse, but we do not know which components are most effective or which populations are most responsive. We do not know how adequate this model is for high risk youth and/or minorities. As boys and girls face different adolescent developmental issues and tasks, it is reasonable to expect that different prevention strategies would work best for each gender. The research done so far does not inform us about that either.
There is not as yet a consensus as to what multiple strategies, in what combinations, are the most effective for which groups of youngsters. The accumulated evidence does, however, support the inclusion of at least the following three components in all adolescent prevention programmes:
- 1. Strategies aimed at changing adolescents' norms, values and expectations about substance use.
- 2. Strategies that build and enhance social and resistance skills.
- 3. Strategies that solidify pro-social community norms and values regarding substance use.
It seems quite likely that resources in the 1990swill be more limited than they were in the 1980s, and we will be forced to choose between important alternatives. Do we, for example, target high risk youth or the general population? The prevention programmes most widely used at the present time may affect the prevalence of alcohol and other drug use among the majority of adolescent participants, but they are failing to reach the 5-15% of teenagers who are at greatest risk of substance use . These are the youngsters who have dropped out of school or are chronic truants. They are the youngsters who have become, or are very likely to become, attached to the criminal justice system. Will we have the resources to target everyone? If not, whom do we target?
Influencing individuals and families to change their substance use behaviour has been the goal of most prevention efforts of the last 20 years. Should we continue to invest most of our prevention energy in that way, or might we attempt to address more strongly the societal forces that influence youngsters to become substance users? Should we dramatically increase the price of legal substances, as Canada recently did with cigarettes? How about banning all cigarette and alcohol advertising everywhere, and raising the legal drinking age substantially?
Finally, up until the present time prevention specialists have developed programmes aimed at ameliorating the risk factors that have been found to be associated with the use of substances. The focus has been on correcting individual deficiencies. Most recently, strategies that foster and enhance individual strengths, and develop resilience factors that protect individuals in stressful situations and environments, have begun to be developed. It is very likely that programmes based on resilience-enhancement strategies will mark the next wave of adolescent substance abuse prevention efforts in the USA.
The New York State Office of Substance Abuse Services supported the project from which this paper was derived. A version of this paper has been published in the Journal of Primary Prevention,Vol.14(1),1993.
Elaine Norman and Sandra Turner, Fordham University, Graduate School of Social Service, 113 West
60th Street, New York, NY, 10023, USA.
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