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Full text of "National Conference on Drug Abuse Prevention Research : presentations, papers, and recommendations : September 19-20, 1996, Marriot at Metro Center Washington, DC"

National Conference on 

rugAbuse 

Prevention Research: 





Presentations, Papers, and 
Recommendations 

September 19-20, 1996 

Marriott at Metro Center 

Washington, DC 




U.S. Department of Health and Human Services 

National Institutes of Health 

National Institute on Drug Abuse 



fONAL INSTITUTE 



National Conference on 
Drug Abuse Prevention 
Research: Presentations, 
Papers, and Recommendations 



MOV I 4 1998 












September 19-20, 1996 
Marriott at Metro Center 
Washington, DC 



Sponsored by: 

U.S. Department of Health and Human Services 
National Institutes of Health 

National Institute on Drug Abuse 
5600 Fishers Lane 
Rockville, MD 20857 

The Robert Wood Johnson Foundation 



In Collaboration With: 

Center for Substance Abuse Prevention 

Community Anti-Drug Coalitions of 
America 

National Prevention Network 






ACKNOWLEDGMENTS 



Zili Sloboda, Sc.D., Director, Division of Epi- 
demiology and Prevention Research, NIDA, pro- 
vided the leadership in planning and directing 
the National Conference on Drug Abuse Preven- 
tion Research and in the coverage and content 
of this conference report. Susan L. David, 
M.P.H., served as conference coordinator and the 
technical editor for this publication. 

The following organizations worked in coopera- 
tion with NIDA in planning the conference: Join 
Together, National Asian Pacific American Fami- 
lies Against Substance Abuse, National Associa- 
tion of Secondary School Principals, National 
Association of Social Workers, National School 
Boards Association, National Families in Action, 
National Parents' Resources Institute (PRIDE), 
National Parent Teacher Association, Operation 
PAR, Inc., and Partnership for a Drug-Free 
America. 

The publication was produced by CMS Commu- 
nications under Requisition #QPQ60102 and 
R.O.W. Sciences under NIDA Contract No. 
N01DA-7-2059. 

To obtain additional copies of this publication, 
contact the National Clearinghouse for Alcohol 
and Drug Information (NCADI) at P.O. Box 
2345, Rockville, MD 20847-2345, 1-800-729- 
6686, or visit its Web site at http://www. 
health.org. An electronic version of the publica- 
tion can be obtained through NIDA's Web site at 
http://www.nih.nida.gov. 



Copyright Status 

NIDA has obtained permission from the copy- 
right holders to reproduce certain previously 
published material, as noted in the text. The 
inclusion of such material does not place it in 
the public domain. Further reproduction of these 
copyrighted materials is permitted only as part 
of a reprinting of the entire publication or chap- 
ter. For any other use, the copyright holder's per- 
mission is required. All other material contained 
in this volume (except quoted passages from 
copyrighted sources) is in the public domain and 
may be used or reproduced without permission 
from the Institute or the authors. Citation of the 
source is appreciated. 

Disclaimer 

The opinions expressed in this publication are 
those of the speakers and authors and do not nec- 
essarily reflect the opinions or official policies 
of NIDA or any other part of the U.S. Depart- 
ment of Health and Human Services. The U.S. 
Government does not endorse or favor any spe- 
cific commercial product or company. Trade, 
proprietary, or company names appearing in this 
publication are used only because they are con- 
sidered essential in the context of the studies 
being described. 



National Institute on Drug Abuse 
NIH Publication No. 98-4293 
September 1998 



PREFACE 

Alan I. Leshner, Ph.D. 

Director 

National Institute on Drug Abuse 



For the past 20 years, the National Institute on 
Drug Abuse has supported extensive research 
into the design and testing of theory-based drug 
abuse prevention interventions that have the po- 
tential for effectively addressing one of 
America's most serious public health problems — 
drug abuse and addiction. At the "National Con- 
ference on Drug Abuse Prevention Research: 
Putting Research to Work for the Community," 
we had the extraordinary opportunity for research 
and community practitioners to work together 
to review the research; explore its ramifications 
for individuals, families, and communities; and 
develop recommendations for future collabora- 
tions and applications of this knowledge in set- 
tings across the country. 

At the conference, we were privileged to hear 
keynote addresses by Donna E. Shalala, Ph.D., 
Secretary of Health and Human Services, and 
General Barry R. McCaffrey, Director of the 
Office of National Drug Control Policy. During 
plenary sessions, five senior scientists from re- 
search institutions across the country presented 
an overview of the risk and protective factors 
that lead to or deter drug use and abuse and de- 
scribed the most effective components of suc- 
cessful prevention programs. They highlighted 
specific approaches to implementing drug abuse 
prevention programs in schools, communities, 
and families. Each scientist expanded on these 
presentations to produce comprehensive papers 
for this volume. Subsequent to the conference, 
two additional research papers on reaching 
at-risk youth and on family-based prevention 
were commissioned to provide additional ex- 
amples of successful prevention interventions. 
To begin building the bridge between research 
and practice, the conference included a series of 



workshops that provided an open forum for the 
interchange between the panel presenters and 
conference participants. These workshops, led by 
a panel of researchers, National Prevention Net- 
work representatives from States, and prominent 
community practitioners, provided opportunities 
to share perspectives and expertise. 

As we all know, research knowledge must be 
applied if it is to have an impact on the drug prob- 
lem. To do that, we need to energize the commu- 
nity of concerned and caring parents, community 
leaders, educators, and governmental officials to 
demand that scientific knowledge be incorpo- 
rated into new and established programs at the 
community level. This conference was the first 
step to help link prevention science to commu- 
nity action. Since then, NIDA has published a 
series of publications on prevention research to 
assist local communities. NIDA published "Pre- 
venting Drug Use Among Children and Adoles- 
cents: A Research-Based Guide," a booklet that 
provides a short summary of research and re- 
sources and references where more information 
can be obtained. NIDA also published a series 
of "Drug Abuse Prevention Publications and Re- 
source Manuals," which describe some of the lat- 
est research, provide a process for determining 
community readiness for prevention, and then 
instruct on how to conduct the intervention. Later 
this year, NIDA will publish a new Research 
Monograph that summarizes the design, 
progress, and outcomes of prevention interven- 
tion studies that focus on the family. It is our 
hope that this conference report will provide a 
valuable resource as you commit your energy and 
enthusiasm to addressing this important public 
health problem. 



in 



CONTENTS 



Preface iii 

Opening Plenary Session 

Welcome and Introductory Remarks 

Alan I. Leshner, Ph.D. 

Director, National Institute on Drug Abuse 1 

Keynote Address 

Donna E. Shalala, Ph.D. 

Secretary, U.S. Department of Health and Human Services 3 

Keynote Address 

General Barry R. McCaffrey 

Director, Office of National Drug Control Policy 

Executive Office of the President 7 

From the Prevention Research Lab to the Community 

Alan I. Leshner, Ph.D 11 

Plenary Session 

Presider: Zili Sloboda, Sc.D. 

Director, Division of Epidemiology and Prevention Research 

National Institute on Drug Abuse 

Risk and Protective Factor Models in Adolescent Drug Use: 
Putting Them to Work for Prevention 

Robert J. Pandina, Ph.D. 

Professor and Director, Center of Alcohol Studies 

Rutgers University 17 

Prevention Programs: What Are the Critical Factors That Spell Success? 

William B. Hansen, Ph.D. 

President, Tanglewood Research, Inc 27 

Preventing Drug Abuse Through the Schools: Intervention Programs That Work 

Gilbert J. Botvin, Ph.D. 

Professor and Director, Institute for Prevention Research 

Cornell University Medical College 43 



Invited Paper 

Reconnecting Youth: An Indicated Prevention Program 

Leona L. Eggert, Ph.D., R.N. 

Reconnecting At-Risk Youth Prevention Research Program 

Psychosocial and Community Health Department, School of Nursing 

University of Washington 57 

Preventing Drug Abuse Through the Community: 
Multicomponent Programs Make the Difference 

Mary Ann Pentz, Ph.D. 

Associate Professor, Department of Preventive Medicine, and 

Director, Center for Prevention Policy Research 

University of Southern California 73 

Advances in Family-Based Interventions To Prevent Adolescent Drug Abuse 

Thomas J. Dishion, Ph.D. 

Research Scientist, Oregon Social Learning Center, Inc. 

University of Oregon 87 

Invited Paper 

Effectiveness of a Culturally Tailored, Family-Focused Substance Abuse Program: 

The Strengthening Families Program 

KarolL. Kumpfer, Ph.D. 1 

Health Education Department, University of Utah 101 

Concurrent Sessions 

Work Group Discussions 125 

Work Group on Risk and Protective Factors 126 

Work Group on Critical Factors for Prevention Success .- 129 

Work Group on Prevention Through the Schools 131 

Work Group on Prevention Through the Community 136 

Work Group on Prevention Through the Family 139 

Day Two: Plenary Session 

Introductory Remarks 

Alan I. Leshner, Ph.D 143 

The Community and Research: Working Together for Prevention 

Elaine M. Johnson, Ph.D. 

Director (Retired), Center for Substance Abuse Prevention 145 

Panel Presentations: 

Is Your Community Ready for Prevention? 

Moderator: Gloria Rodriquez, Ph.D. 

Project Manager, State Needs Assessment Project 

New Jersey Department of Health 151 



1 As of this printing, Dr. Kumpfer is director of the Center for Substance Abuse Prevention, Substance Abuse and Mental 
Health Services Administration, DHHS. 

vi National Conference on Drug Abuse Prevention Research 



Panel Presentations: 

William F. Crimi 

Executive Director, Franklin County Prevention Institute 154 

Harry Montoya 

President and CEO, Hands Across Cultures 157 

Thomas J. Connelly 

President, Life Skills Training Curriculum 159 

Open Forum and Closing Session 

Introductory Remarks 

Alan I. Leshner, Ph.D 163 

How Can Prevention Research Help the Community? 

Moderator: James E. Copple 2 

President, Community Anti-Drug Coalitions of America 163 

Work Group Reports 

Work Group on Risk and Protective Factors 167 

Work Group on Critical Factors for Prevention Success 168 

Work Group on Prevention Through the Schools 169 

Work Group on Prevention Through the Community 171 

Work Group on Prevention Through the Family 172 

Closing Remarks 

Alan I. Leshner, Ph.D 175 

Conference Speakers 177 

Panel and Work Group Participants 179 



2 At this printing, Mr. Copple is director of Coalition, State, and Field Services, National Crime Prevention Council. 

vii 



OPENING PLENARY SESSION 

Welcome and 
Introductory Remarks 

Alan I. Leshner, Ph.D. 

Director 

National Institute on Drug Abuse 



I am pleased to welcome all of you to what I 
hope will prove to be a landmark meeting and 
event, bringing together people from all sectors 
of our society to face the problem of drug abuse. 
I am particularly pleased to be able to welcome 
you on behalf of our cosponsor, the Robert Wood 
Johnson Foundation, and on behalf of our col- 
laborators, the Center for Substance Abuse Pre- 
vention, the Community Anti-Drug Coalitions 
of America, and the National Prevention 
Network, as well as a long list of cooperating 
organizations. 

I think the breadth and the diversity of the groups 
and the individuals represented here speak not 
only to the importance of the problem, but to our 
Nation's commitment to actually doing some- 
thing about it. We are here today on behalf of 
millions of American youth who are at risk of 
having their lives ravaged by drugs. Our task 
today is straightforward: to come together as 
Federal, State, and community leaders to discuss 



and to decide how best to bring the full power of 
science to bear on preventing the devastation of 
our youth. 

I am particularly pleased today that we have two 
of America's most important leaders with us to 
set us on our course: Donna E. Shalala, the Sec- 
retary of Health and Human Services (HHS), and 
General Barry R. McCaffrey, the Director of the 
President's Office of National Drug Control 
Policy. 

I now would like to introduce to you Secretary 
Donna Shalala, who was the first woman to head 
a "Big 10" university, the University of Wiscon- 
sin at Madison, where she nourished not only 
great research, but also a Rose Bowl-winning 
football team. She was the president of Hunter 
College, at that time the youngest person ever to 
be a college president, and is a great and life- 
long leader for the children of our country. 



Opening Plenary Session 1 



Keynote Address 



Donna E. Shalala, Ph.D. 

Secretary 

U.S. Department of Health and Human Services 



I am honored to join all of you today. Behind the 
research, behind the science, and behind the sta- 
tistics, the work that you do every day is really 
about saving lives, preserving families, and build- 
ing stronger communities for the future of our 
country. 

That future begins and ends with our young 
people, including the young people General 
McCaffrey and I spoke about several weeks ago 
when we released the results of the 1995 Na- 
tional Household Survey on Drug Abuse, which 
was conducted by the Substance Abuse and Men- 
tal Health Services Administration (SAMHSA). 
The Household Survey showed that the increase 
in drug use among youth that began with eighth 
graders in 1991 continued to climb last year. 

I know that all of you join me and General 
McCaffrey in calling on every American to join 
forces to reverse this trend once and for all. As 
our children go back to school this month, full 
of hope and promise for the future, now is the 
time for us to make sure that drugs do not stand 
in their way. 

But this is not the time to point fingers. We must 
not allow this issue to become a political foot- 
ball because that could send the wrong message 
to our children. It will make them think that drugs 
are an issue just for the politicians rather than 
something for which they have to take personal 
responsibility. Drugs are not a Republican or 
Democratic problem. They are a bipartisan prob- 
lem and an American problem. Our problem. 
They present a challenge for all of us, a chal- 
lenge that demands real leadership. And that is 
exactly what President Clinton has provided to 
the American people with the most comprehen- 
sive antidrug strategy to ever come out of 1600 



Pennsylvania Avenue. The President's plan at- 
tacks the supply side of the problem with tough 
law enforcement and interdiction. It hits at de- 
mand with resources for treatment, education, 
and prevention, and it includes a strong commit- 
ment to drag abuse research. I am proud to serve 
with a President who understands the vital role 
that your work plays in our fight against drags, 
and I am proud of the strides being made every 
day at the National Institute on Drug Abuse 
(NIDA). 

Thanks to some of the world's best scientists, 
we have made very big gains in understanding 
the unique dangers posed by individual drags and 
in finding new solutions to combat them. Now 
that NIDA scientists have found a way to immu- 
nize animals against the psychostimulant effects 
of cocaine, we are one step closer to finding a 
treatment for cocaine addiction. As part of the 
Marijuana Use Prevention Initiative I launched 
in 1994, NIDA-sponsored research continues to 
illuminate the dangers of marijuana. Research- 
ers like Dr. Billy Martin have demonstrated that 
marijuana is addictive, and researchers like Dr. 
Peter Fried have shown that marijuana use dur- 
ing pregnancy can have dangerous long-term 
effects on children. 

In the face of rising marijuana use among our 
young people, these breakthroughs in scientific 
knowledge do more than shed light. They have 
the potential to save lives. We need to educate a 
generation of parents, doctors, police officers, 
teachers and everyone else who cares about chil- 
dren that marijuana is a dangerous drag. Let me 
be clear: We need to make the scientific case, 
lay out the facts, and tell all Americans exactly 
why marijuana is hazardous to our health, to our 



Opening Plenary Session 3 



heart, lungs, brain, and motor skills, and ulti- 
mately to our future. 

But there's another critical role for research as 
well. We need to hold our education and preven- 
tion efforts to the very highest standards of rig- 
orous scientific evaluation. We need more 
information about what works and what doesn't, 
and we need to bring that knowledge to every 
home, school, and community in America. 

Over the next 2 days, you will hear more about a 
number of key research findings that will help 
illuminate how we can save our children from 
the scourge of drugs. Let me touch on three of 
the most important findings. 

First, I am pleased to see that research done by 
Dr. Gilbert Botvin of Cornell University and oth- 
ers is showing the value of school-based preven- 
tion programs. From years of research we know 
that schools often give us the best chance of 
reaching the children who are most at risk for 
substance abuse, including children with behav- 
ioral problems or learning disabilities. This re- 
search confirms the wisdom of President 
Clinton's fight to save the Safe and Drug-Free 
Schools program, a powerful resource, and one 
with bipartisan roots, that serves about 40 mil- 
lion schoolchildren in 97 percent of America's 
school districts. Last year, the President used his 
veto pen to protect this critical initiative from 
massive congressional cuts. This year the Con- 
gress has proposed big cuts again, and once again 
we must lay down our marker and say, "No." 
We must make it clear that now is not the time to 
roll back our commitment to protect children 
from drugs in their schools. Now is the time to 
strengthen that commitment by extending a hand 
to parents and children to help them win this 
fight. 

That is why I am proud to announce today a new 
partnership between HHS, NIDA, and Scholas- 
tic News magazine to bring even more drug edu- 
cation right into America's classrooms. In 
November, more than 73,000 third- through 
sixth-grade teachers will receive new materials 
designed to educate 2.3 million students about 
the dangers of inhalants, marijuana, and tobacco. 
But that is not all. Our program includes a take- 
home component that lets parents know what 
their children learned in school that day and asks 



them to reinforce that strong antidrug message 
around the dinner table. 

That brings me to my second finding. Dr. Thom- 
as Dishion of the Oregon Social Learning Cen- 
ter will present research showing that parents and 
families are powerful forces for preventing youth 
drug use. Our challenge is to put power in par- 
ents' hands and to inspire them to talk early, of- 
ten, and candidly with their children about drugs. 
What works is parents talking to their children 
about drugs and at every opportunity reinforc- 
ing the core message that drugs are illegal, dan- 
gerous, and wrong. That has never been more 
important than right now. 

In a recent survey of teens and parents conducted 
for the Center on Addiction and Substance Abuse, 
65 percent of parents who used marijuana in their 
youth have resigned themselves to the belief that 
their own children will try drugs. Forty percent 
of these parents believe they can do little to pre- 
vent this tragedy, but that is as far from the truth 
as Moscow is from Maine. The fact is that chil- 
dren trust their parents more than any other 
people in the world. We have to make sure par- 
ents know this and act to protect their children. 

For this reason we are teaming up with leaders 
such as the National Parent Teacher Association 
(PTA) to conduct a new "Reality Check" cam- 
paign that has already given a free publication 
to 1 million parents to help them send strong no- 
drug-use messages to their children, even if the 
parents experimented with drugs in the past. We 
do not want parents to wait until their children 
have been exposed to drugs on the playground 
or at a friend's house. They need to start 
early, which is the third key finding that I want 
to amplify today. 

From research by Dr. Dishion and others, it has 
been shown that it is particularly beneficial for 
young children, especially those at risk, to hear 
clear and consistent no-drug-use messages early 
and often throughout their preadolescent years. 
Think about some of the earliest messages kids 
receive from parents and other adults, the time- 
honored ones: "Do not touch that hot stove." 
"Look both ways before crossing the street." "Do 
not talk to strangers." We never forget them, and 
more important, we pass them on to our chil- 
dren. Make no mistake about it. Our children 



National Conference on Drug Abuse Prevention Research 



would fare much better as teenagers and adults 
if that repertoire of traditional messages also in- 
cluded repeated warnings to stay away from 
drugs. In fact, survey data from the Partnership 
for a Drug-Free America shows that children tend 
to have strong antidrug attitudes up until age 12. 
But those attitudes begin to erode just before the 
teen years as kids start to receive an assault of 
pro-drug-use messages from popular culture and 
other sources. 

Let us look at the facts. In 1991, drug use among 
eighth graders jumped, signaling the beginning 
of the trend among all teens that we are still ex- 
periencing today. If we are going to move in the 
other direction and reduce the numbers, the place 
to make progress first is with the youngest 
group — eighth graders — by increasing their dis- 
approval of drugs and increasing their percep- 
tion that drugs are harmful. But we cannot wait 
until they hit the eighth grade to do that. To lower 
our eighth graders' drug use rates, we must start 
earlier, bolstering their initial antidrug attitudes 
and sustaining them beyond age 12 so that they 
do not soften their disapproval of drugs as they 
grow into their teens. 

That is the challenge I want to bring to you to- 
day. So, how do we do that? How do we influ- 
ence our young adolescents? What kind of 
messages are persuasive to children ages 8 to 12? 
Who are their role models? Who do they trust 



most? How do we compete and win against the 
barrage of pro-use messages? We need science- 
based guidance to answer these seemingly simple 
questions because the answers to them are com- 
plex. We need to take the science and these an- 
swers and translate them into action by using 
them anywhere that they can help us win the 
battle for the hearts, minds, and futures of our 
children. 

We cannot stand still in this fight because, as we 
stand at the doorway to the 2 1 st century, some- 
where in America there is a 10-year-old girl who, 
if she stays off drugs, could become the CEO of 
a Fortune 100 company. There is a 14-year-old 
boy who learned to say no in grammar school 
who now dreams of becoming the next Ameri- 
can astronaut to walk on another planet. And 
there is the 1 8-year-old girl who learned to resist 
drugs in sixth grade and now can set her sights 
on any job she wants, from the future principal 
of her high school to the future President of the 
United States. 

These young people are our national hope and 
our national resource. With the vast promise of 
science and research, we can reach them better 
and earlier and in doing so reverse these drug 
trends and paint a brighter future for this gen- 
eration and every generation to come. By work- 
ing together, we will do just that. Thank you. 



Opening Plenary Session 5 



Keynote Address 

General Barry R. McCaffrey 

Director 

Office of National Drug Control Policy 

Executive Office of the President 



Let me thank Secretary Shalala for including me 
in today's activities, and certainly Dr. Alan 
Leshner, the NIDA Director. I embarrass him fre- 
quently because I boast about his leadership and 
his example, along with others, including Nelba 
Chavez, Elaine Johnson, David Mactas, the 
people in the Justice Department, and the people 
in the Department of Education, who provide me 
with background information on those aspects 
of the drug challenge that I need in order to seri- 
ously address policy options in this arena. 

One of Dr. Leshner's slogans is one that I have 
adopted: "By the turn of the century we are go- 
ing to replace ideology with science." The bot- 
tom line is that I know far more definitive 
information about North Korean nuclear weap- 
ons than I do about heroin addiction, who is 
taking heroin, why they are doing it, and what 
treatment methodologies work. That is a 
disgrace, and that is why this conference is so 
enormously important to all of us. 

Let me briefly salute people like Dr. Robert 
Pandina at Rutgers University, Dr. Gilbert Botvin 
at Cornell University, Dr. Mary Ann Pentz at the 
University of Southern California, Dr. Thomas 
Dishion at the Oregon Social Learning Center, 
and Dr. William Hansen at Tanglewood Re- 
search, and those of you who came here from all 
over the country. You are very busy people who 
have come to share your thinking about what is, 
unarguably in my own judgment, the key issue 
in the national drug strategy: the prevention of 
drug abuse. Many of you have devoted your en- 
tire adult lives to trying to understand and deal 
with the problem of substance abuse in America. 



What the National Drug Strategy represents is 
what our President put forth to the American 
people a few months ago in Miami. We wanted 
to emphasize a comprehensive approach to ad- 
dressing substance abuse in America rather than 
just picking one variable and addressing that. 

I think cancer may be akin to the type of prob- 
lem you and I are facing with substance abuse. 
First of all, substance abuse, like cancer, is a fairly 
common challenge that most families have faced. 
You have to do pain management, and you have 
to get to the root cause. You take 5 -year survival 
rates and talk about the dignity of the individual. 
You take a holistic approach. 

The President faced the American people and said 
that our drug abuse strategy has to be a long- 
term engagement. It is not a military campaign 
but rather a very complex social, medical, legal, 
and law enforcement issue. It will be solved not 
by Washington, but by parents, school teachers, 
ministers, coaches, and community coalitions, 
and, it is hoped, with the very direct involve- 
ment of the research community. This involve- 
ment has been the missing factor. 

You and I learned in Philosophy 101 that you do 
not argue about facts. They either are facts or 
they are not facts. You have to start with a set of 
common assumptions to have any kind of seri- 
ous discussion of policy alternatives. These as- 
sumptions are part of our challenge. We are still 
arguing about the facts. A lot of our data are soft 
and inadequate. If you are a serious scholar in 
the field, you understand the limitations of your 
own data. On the other hand, there is a lot that is 



Opening Plenary Session 7 



known, and certainly there is a mountain of an- 
ecdotal information to buttress many of the ar- 
guments you make, particularly in the field of 
drug prevention. 

We have to move forward in some systematic 
fashion so that we end up with conclusions based 
on scientific analysis that are subject to peer 
group review and can be reproduced by other 
investigators. That is where we need to go, and 
we need researchers to help us. One of the many 
joys of this job is to be able to talk to members 
of the research community, hear what you are 
doing, and learn about your conclusions as they 
emerge. 

The National Drug Strategy has five goals. Any 
cunning bureaucrat in Washington learns early 
on that you do not tell people what your priori- 
ties are. If you have 10 priorities, those people 
who hear they made priority number 4 or num- 
ber 8 are enraged and want to know why they 
cannot be number 3 or number 7. So we do not 
have multiple priorities in the National Drug 
Strategy — we have only one. Absolutely with- 
out question, the single priority is to motivate 
American youth to reject substance abuse. 

We understand, both on an intuitive level and 
from experience in studies, that if American kids 
can get from sixth grade to age 20 without smok- 
ing cigarettes, abusing alcohol, or using illegal 
drugs, they are "home free," statistically speak- 
ing, and will not suffer addiction problems for 
the remainder of their lives. 

You and I essentially are concerned about only 
two facts. The first fact is that when people use 
illegal drugs or abuse alcohol, they experience 
intense pleasure. I think we have been inadequate 
in telling young people up front that this is why 
people use drugs. There is a pleasure-seeking 
dimension to it. The second fact is that drugs 
cause you to act like a jerk, and we have not made 
that point. We have not said that heroin abuse 
also gives you enormous nausea, makes your skin 
crawl, constipates you, and diminishes your sex 
drive. Now, that is the "good" news about heroin 
use. The bad news is that, as with most addictive 
substances, you develop drug dependency and 
tolerance, and your life becomes one of unend- 
ing misery from trying to satisfy this addiction. 



And this second dimension is a tough one be- 
cause, as you know better than I, once you are 
addicted, the challenge is to effectively treat the 
addiction. 

Along with this challenge is the relapsing nature 
of the disorder and the way we provide treat- 
ment. Our limited therapeutic tools are a big 
problem. Getting folks unhooked from the re- 
wired neurochemical brain processes of drug 
addiction is a tough challenge at best, but we 
think it is doable and certainly worth the money. 
It is a no-brainer for a taxpayer to want to 
invest in drug treatment, but treatment itself is 
difficult. 

So drug use prevention for the 68 million kids 
18 years and younger is what we are going to 
focus on. It is the spearhead of the whole effort. 

Secretary Shalala already mentioned one of our 
challenges: we have stopped talking to kids about 
drugs. You and I know heroin is an enormous 
risk. Eighty-five percent of us will say that, 
but 50 percent of 12- to 17-year-olds say they 
fear heroin experimentation. We have not been 
talking to the children. 

The news media stopped focusing on it. The 
school systems backed off, saying they felt in- 
adequately equipped, and they were not sure it 
was an appropriate role for them. And the minis- 
ters, where are the ministers? We simply have to 
send a consistent prevention message appropri- 
ate for each age group to children from kinder- 
garten through the 12th grade. If we do, then 
more adolescents and children will not be ex- 
posed to these drugs and become at risk of 
addiction. 

We have to remind ourselves that drug use is not 
inevitable: 80 percent of our children have never 
touched an illegal drug. But we do have a prob- 
lem, and we have to get moving. We have to get 
organized. We also are going to have to listen, 
and I think the renewed election year debate 
about drug use is probably a very helpful thing. 
In the flurry of body blows, the American people 
and the news media inevitably will come to 
balanced, correct conclusions. 

We have a 1997 budget before Congress now, 
and we need help. We need to get the budget of 



8 National Conference on Drug Abuse Prevention Research 



$15.1 billion and the $250 million supplemental 
funding request passed by Congress. Most of that 
money is for law enforcement and prisons, and 
that is okay. Drugs are wrong, and you have to 
uphold the law. We must have law enforcement 
authorities address the issue because if we do 
not, prevention, education, and treatment mes- 
sages will not work very well. But having said 
that, I also believe that we have created an Ameri- 
can gulag. We have 1.6 million people behind 
bars, and probably two-thirds of those in the Fed- 
eral system are there for drug-related crimes. 

We are having a difficult time making an ad- 
equate case to responsible men and women in 
Congress, State legislatures, and city councils 
that drug prevention works. I need your help. You 
need to make the case, and you need to talk to 
your Government representatives at the State, 
local, and Federal levels. You need to back up 
what you have intuitively learned throughout 
your professional careers — that drug prevention 
is the absolute centerpiece of a sensible national 
drug strategy. 

Let me also ask you to do several additional 
things. It seems to me you have to speak to the 
news media more frequently. Come forward and 
help us make the case. We have a debate right 
now — Proposition 215 in California is simply 
outrageous, and Proposition 200 in Arizona is 
incredible. It is unclear what those two proposi- 
tions will do. But what Secretary Shalala, law 
enforcement officers, and I do know is that it is 
bad science and bad medicine. It also will ex- 
pose children in California and Arizona to wide- 
spread use of another psychoactive substance 
[marijuana], which we believe, along with ciga- 
rette smoking and alcohol abuse, is absolutely a 
gateway behavior that sets kids up to lose in life. 
We have to do something about it. 

Who is in the debate? The people who ought to 
speak to the issue are the professionals who un- 
derstand it, and that includes you, the medical 
community, treatment community, and preven- 
tion community, along with parents, educators, 
and others who have responsibility for children. 
We simply have to stand up in that debate. 

I would like to suggest a final note of optimism 
that has been lacking in this entire issue. I com- 
monly have people clap me on the back and say 
what a brave lad I am to sign up to work on a 



problem that seems impossible to break out of. 
Am I not industrious for agreeing to take on this 
whole challenge? I told the President there are 
only two things that I bring to the table that are 
unique. One overwhelming credential I bring to 
the table is that I was confirmable by the Senate. 
But the second one is a sense of optimism. I have 
three grown kids who married people who are 
like them. They are drug-free and they are re- 
sponsible, hard-working youngsters, like most 
of America. The overwhelming majority of 
Americans do not use illegal drugs and do not 
have substance abuse problems. Our problem is 
that many Americans do. 

I watched the U.S. Armed Forces go through this 
issue in the 1970s. It was a nightmare. If you 
were in uniform between 1971 and 1981, [you 
know that] the impact of substance abuse on our 
professionalism, discipline, and spiritual 
strengths was beyond belief. About one-third of 
the Armed Forces were using drugs all the time, 
and maybe another third would use them when 
they could get their hands on them. I do not know 
which was worst: marijuana, Quaaludes, or al- 
cohol. They were all mixed in there and had a 
destructive effect on our physical and moral abil- 
ity to defend America. We worked our way out 
of it, and contrary to what many people believe, 
we did not do it through punishment. We did it 
because we had an advantage over civilian insti- 
tutions, called sergeants. These sergeants were 
men and women ages 25 to 35, who cared about 
the 19-year-olds under their control. They set 
standards and articulated a work atmosphere of 
dignity, caring, and monitorship. I might add it 
took us nearly 10 years to get out of it, and drug 
testing was a key component of that effort. Drug 
testing is a tool that is not necessarily available 
in American society. We prize our liberty and 
our right to privacy, so we cannot assume that 
we can go about this problem as Singapore does 
or as the U.S. Marine Corps does. 

But the youngsters in the Armed Forces are the 
same beautiful people that are here in the streets 
of Washington and in your community, and they 
respond to the same motivations. I would sug- 
gest that we take a long-term approach and en- 
courage a sense of partnership. You have the most 
important task of all — drug education and pre- 
vention. You have to tutor us and the American 



Opening Plenary Session 9 



people, using information from scientific inquiry, Riley, and I will take the results of your work 
about what works and what does not work. You and be your public servants, 
can assume that Secretary Shalala, Secretary 



10 National Conference on Drug Abuse Prevention Research 



From the Prevention Research 
Lab to the Community 

Alan I. Leshner, Ph.D. 

Director 

National Institute on Drug Abuse 



I have been in the Government for 17 years, and 
I have to tell you that in those 17 years I have 
never met two people who bring to the most com- 
plex problem facing us the kind of clarity of 
thinking, focused action, and courage that Sec- 
retary Shalala and General McCaffrey do. I sa- 
lute both of you, and I thank you for leading us 
all. 

I also want to take a moment to acknowledge 
our very important central collaborator in the 
Scholastic News magazine project that Secretary 
Shalala mentioned. Rick Delano, the director for 
the Youth Health Initiative at Scholastic News, 
is in our audience. He pointed out to me earlier 
today that it was about a year ago that we first 
started talking about holding a conference on 
prevention research. He actually posed it as a 
challenge back then when he said to me, "So you 
think you have such good science? Do it." Well, 
we are doing it. 

My job is to try to set a broad context for this 
conference and, as much as I can, to lay some of 
the groundwork and spell out some of the gener- 
alizations that we have derived from prevention 
science over the years. Many of these generali- 
zations may appear superficially to be common- 
sensible, but they are not. The problem is that 
science is the process by which common sense 
gets revised; that is to say, today's truth or com- 
mon sense may not be tomorrow's common 
sense. 

Those of you who work with children know 
this as well as anyone. Children are born a blank 
slate, and we have learned much about the abil- 
ity of infants to acquire knowledge and their 
immediate perceptive and learning abilities. 



We all need to keep in mind that drug abuse and 
addiction are among the top one or two issues 
facing this country and our society. The reason 
is that drug abuse and addiction affect everybody, 
either directly or indirectly: every family, every 
community, and all parts of society. 

About 70 million adult Americans have used 
drugs at some time in their lives, and therefore 
they think they are experts on what to do about 
drug problems. It is a bit like the problem expe- 
rienced by educators; everybody went to school 
so everybody feels free to tell their teachers how 
to teach. How many people in this room have 
not done that? 

I am probably the only NIH Institute Director 
who goes to a cocktail party and the first 12 
people who come up to me tell me how to fix the 
drug problem. The head of the National Cancer 
Institute does not have that conversation. The 
head of the National Heart, Lung, and Blood 
Institute might be told not to eat the high- 
cholesterol roast beef, but other than that, people 
are not giving him the same type of advice. 

The problem is that we as a society, and frankly, 
many in the professional community as well, 
have tremendous ideologies, that is, tremendous 
beliefs and intuitions about the nature of drug 
abuse and addiction and what to do about it. The 
good news is that we also have scientific data 
that we can bring to bear on the problem. We 
need to talk about the data, and we need to fig- 
ure out how to actually accomplish our goal. 

When I first became the NIDA Director I went 
to visit the Partnership for a Drug-Free America, 
and I was struck by the Partnership's slogan: 



Opening Plenary Session 11 



"Drug abuse is a preventable behavior. Drug 
addiction is a treatable disease." That slogan cap- 
tures both the simplicity and the sophistication 
of what 20 years of science has taught us, and I 
want to spend some time talking about both sides 
of that. 

I am going to start on the treatable disease side. 
Whenever we think and talk about drug use or 
the phenomenon of addiction — and you will no- 
tice that I never pretend they are the same word — 
I think it is important to understand the full 
complexity of the issue that we are dealing with. 

Let me start with some simple points. Whether 
or not a group of people will use drugs is a func- 
tion of a large variety of factors called risk fac- 
tors. However, when you look at what we call 
the proximal cause, that is, the reason a person 
takes a drug at a particular point in time, we find 
that he or she takes that drug not because of a 
risk factor, but to modify his or her sense of well- 
being. They are taking that drug to modify their 
mood, their perception, and sometimes their 
motor skills. And what they are doing, in fact, is 
modifying their brains. 

The truth is that people take drugs to modify their 
brains, and they like modifying their brains with 
drugs. Positron emission tomography (PET) 
scans, from work by Nora Volkov and her col- 
leagues at the Brookhaven National Laboratory, 
graphically demonstrate the phrase, "This is your 
brain on drugs." What her scans show is the up- 
take of radioactive cocaine over time into the base 
of the brain. People take cocaine because of that; 
they love the concentration of cocaine in that part 
of their brain. And we have a sophisticated level 
of understanding about why they love it. What 
they are doing actually is pushing up the dopa- 
mine levels in that part of the brain. PET scan 
studies on rats given cocaine show spikes in 
dopamine, the neurotransmitter involved in 
Parkinson's disease and involved in most pleas- 
urable experiences. When a rat takes the cocaine, 
there is a dopamine surge. We believe the major 
reason that rats take cocaine is to obtain that 
dopamine surge. It is true for nicotine, and it is 
true for marijuana, amphetamines, and heroin. 
They all lead to an increase in dopamine. 

The problem with taking drugs to modify 
the brain is that people who take drugs have 



succeeded too well, and prolonged drug use 
modifies their brains in fundamental and long- 
lasting ways. PET scans show that there is a rela- 
tively permanent change in the brain that lasts at 
least 100 days after an individual has stopped 
taking cocaine. The question most of you are 
asking at this moment is, "Does it return to nor- 
mal?" The answer to the question is, "I don't 
know." One of the sad things about science is 
that we often obtain half of the answer to a ques- 
tion and do not get the rest. We are working on 
the rest of the answer. 

Addiction is, in fact, a condition of changed 
brains. That is, you take drugs in order to change 
your brain. Sadly, you become too good at it, 
and over time it produces long-lasting, and in 
many, many cases, dramatically harmful effects 
on your brain. Addiction is a condition of 
changed brains, and I will tell you that it would 
be a lot easier if that was all it was. I could say, 
"It is just a brain disease." I could find a magic 
bullet. But I have to tell you, there will be no 
magic bullet. Those of you who are expecting a 
magic bullet — forget it. This is the most com- 
plex problem we have ever found, and we will 
have to find complex solutions. 

We know that addiction is not just a condition of 
changed brains. It is also a result of a variety of 
factors that become embedded in the addiction 
itself. In this case I would refer you back to the 
concept of people, places, and things. The truth 
is that the circumstances that accompany the 
development of an addiction become what we in 
psychology call "conditioned." These circum- 
stances become a conditioned part of the addic- 
tion, and they are able to elicit phenomenal 
cravings. The cues around drug use, not just the 
drugs, can elicit tremendous cravings. 

Work from the University of Pennsylvania meas- 
ured the level of craving experienced by a co- 
caine addict. They compared levels of craving 
in response to neutral stimuli, like a nature video, 
with the level of the craving elicited by expo- 
sure to cocaine stimuli, such as the parapherna- 
lia used for crack cocaine. No actual drugs were 
involved. Researchers found that exposure to the 
cocaine stimuli alone elicited phenomenal crav- 
ing. This is why people in the treatment commu- 
nity know that you cannot just complete an 



12 National Conference on Drug Abuse Prevention Research 



inpatient treatment experience and dump the pa- 
tient back in the community. You need to have 
aftercare that deals with the embedded social cues 
that occur. 

PET scans show what I call the memory of drugs, 
or the activation of the part of the brain called 
the amygdala. The amygdala is a part of your 
brain, not surprisingly, related to all emotional 
experiences, and particularly the memory of 
emotional experiences. The scans show the acti- 
vation of the amygdala in response to the co- 
caine video compared with the nature video. 
They show the quintessential biobehavioral dis- 
order. That is to say, this is the epitome of biol- 
ogy and behavior coming together. We 
understand much of the brain mechanisms, and 
we understand the effects of the social and be- 
havioral context and the behavioral expression. 
The PET scans tells us about the complexity 
of addiction and they tell us about its solutions. 
And there are solutions. Addiction has to be seen 
as a condition of changed brains and trained or 
conditioned brains. 

The task of drug addiction treatment becomes 
changing the brain back to normal. You can do it 
in a variety of ways, including pharmacologi- 
cally in some cases, although we basically have 
medications only for heroin addiction and nico- 
tine addiction. We have no medications for co- 
caine addiction, but we are working on it. 

However, we do have a wide range of impres- 
sive treatment approaches. Drug addiction is 
treatable. A few weeks ago at the American Psy- 
chological Association, Dr. Marcia Lenehan from 
the University of Washington articulated the 
goals of treatment: enhancing the individual's 
capabilities, improving motivation, and assuring 
generalization to the natural environment. There 
are at least three approaches to accomplishing 
each of those goals that have been proven effec- 
tive through clinical trials. This is science being 
brought to bear on the problem of addiction. 

We have data to show that you can accomplish 
each of those goals, but we have a tremendous 
gulf between what we have learned from science 
and incorporating these approaches in some treat- 
ment settings. More and more treatment settings 
are being exposed to these scientific findings and 
are modifying their treatment approaches. But 



the fundamental point is that addiction is treat- 
able, and we have a wide array of tools in the 
toolbox with which we can accomplish that goal. 

But we are here today to discuss drug use as a 
preventable behavior. The big question is, how 
do you go about preventing drug use? The truth 
is that a tremendous amount of ideology exists 
in our communities, among our professionals, 
and, to be candid, among some of our scientists 
as well. It is one of the most frustrating prob- 
lems that I have. We have people who do not 
understand that prevention can be science based. 
It is like any other phenomenon. There are two 
tasks: to design and test new prevention ap- 
proaches, and to test the efficacy of existing ap- 
proaches. Both of these tasks are scientific goals 
and are achievable goals. 

So what is this science base that we are here to 
talk about? Primarily, you need to understand that 
prevention, although it is very complex, is fun- 
damentally a process of education and of behav- 
ior change. Much of the science base that should 
and can be used in the development of drug use 
prevention approaches comes from the science 
of behavior change. It comes from the study of 
epidemiology, patterns of drug use, histories of 
use, and risk and protective factors. As I am fond 
of saying, prevention should be experimental 
epidemiology and experimental behavior change. 
We should take what we learn from basic sci- 
ence and translate it into prevention science, and 
we should take prevention science and translate 
it into practice. And that is what we are trying to 
do. 

Science has taught us a lot. We have had at least 
20 years of scientific research on the principles 
of drug use prevention, and we have learned a 
tremendous amount. Our colleagues and you who 
are the users of prevention science will work to- 
gether to put details on the generalizations that I 
will discuss. What is sophisticated here is un- 
derstanding how to move from generalities to 
specifics and understanding how to do some 
things and not do other things. 

Let us start with some understanding of risk fac- 
tors for drug abuse. Science has identified more 
than 70 risk factors for drug abuse, and they are 
very powerful. However, they are not equally 
powerful, and I am not going to go through all 



Opening Plenary Session 13 



of them in detail. They operate at multiple lev- 
els: the individual level, the family level, the peer 
group level, and the community level. Those 
70 risk factors are the same risk factors for 
everything bad that can happen to somebody. 

I am a public health official and a parent. The 
truth is that if I could modify any of those bad 
things through a prevention program, I would 
be pretty happy. But my job is to deal with the 
issues of drug abuse per se, and therefore we have 
to select the most powerful risk factors and the 
most powerful interactions among these complex 
behaviors. We also need to understand that the 
level of risk, that is, the variation in level and the 
form of risk, must dictate the form and the 
intensity of the prevention effort. The one-size- 
fits-all approach never works. Anybody who 
thinks a single approach is going to work for 
everybody is naive. 

Not only is it true that the higher the level of 
risk, the more intensive the prevention effort must 
be, but also the earlier we need to begin those 
efforts. Another critical point and fundamental 
principle is that prevention programs must be age 
specific. That is, you cannot speak to young chil- 
dren in the same way you speak to older chil- 
dren. You cannot speak to younger teenagers in 
the same way you speak to older adolescents. It 
is a tough lesson to learn, but science has taught 
us this over and over again. The advertising in- 
dustry figured this out 30 years ago. Where have 
we been? All of our programs must be age ap- 
propriate and age specific, and they must also be 
culturally appropriate. They must speak to the 
people to whom they are directed and not only 
to the people who are doing the speaking. 

It also is true that just dealing with risk factors is 
not going to be sufficient. A heartening fact is 
that most of the children considered to be at high- 
est risk do not use drugs. Why is that? What cir- 
cumstances prevent drug use among the most 
high-risk kids, and are there insights to be de- 
rived from understanding why this occurs? This 
could be useful in the prevention arena. 

We have come to believe, on the basis of research 
that you will hear throughout this conference, 
that the best prevention approaches take into 
consideration both risk factors and protective and 
resiliency factors, and they overlay protective or 



prevention factors onto an understanding of the 
risk factors. We have been trying to figure out 
the best way to conceptualize this. The truth is 
that you also need to, as we say in science, 
titrate one or the other as one varies. As risk fac- 
tors vary, you need to modify the protective fac- 
tor approach, and as you change the protective 
factor approach, of course, you often will reach 
different groups of people. 

Let me give you an example. Science has taught 
us that one of the most powerful protective fac- 
tors is family involvement in the life of the child. 
You will notice that I did not say family involve- 
ment just in the child's drug use. There is an 
important difference. It is not very effective for 
daddy to come home from a hard day's work, 
walk in the house, say, "Hi. I am home. Do not 
use drugs." This is not going to work. What is 
needed, and what we have come to understand, 
is that family involvement in the life of the child 
is a powerful protective factor. There is a techni- 
cal term I actually do not like very much, "pa- 
rental monitoring," but the concept is important. 
Parents need to be involved in their children's 
lives and ask them questions such as "Where 
are you? What are you doing? Who are your 
friends? How are you? What are your problems? 
Do not use drugs. What else is going on? Did 
you do your homework? We love you." This 
involvement has to be part of a constellation of 
interactions. 

To the point of titrating risk and protective fac- 
tors, we know that approaches to strengthening 
the family must be changed and adapted as we 
move to more and more high-risk situations. In 
the most high-risk situations, concentrating on 
the family alone is not going to be sufficient. You 
need to adjust or titrate the relationship between 
risk and protection. 

Another point is that prevention programming 
has to match the nature of the problem in the 
local community. This is another area in which 
one size does not fit all. It will never happen. 
One of the things NIDA has slowly begun to do 
is more systematic, local epidemiologic research. 
We need to match the programming to the par- 
ticular situation in the community. 

We need to focus on drug use and not just indi- 
vidual and specific drugs. Sometimes we need 



14 National Conference on Drug Abuse Prevention Research 



to address a specific drug. For example, we are 
all concerned about the use of methamphetamine 
beginning to rise. Our Institute is mounting a 
major methamphetamine initiative. Other parts 
of the Government also have mounted metham- 
phetamine initiatives to do a preemptive strike 
on the increases that seem to be occurring in 
methamphetamine use. But prevention program- 
ming in general must deal with drug use and not 
just individual drugs. 

I am a basic scientist by background, and I 
worked for many years at the laboratory bench 
and at the National Science Foundation. My wife 
is the head of child welfare services in Mont- 
gomery County, Maryland. One night she told 
me about case management, and I was really in- 
trigued. Then I thought for a few minutes and 
said, "What do you mean? How could you not 
case-manage?" This is sort of a truism. The prob- 
lem is you have to move from that truism to how 
do you "do" case management. And it is not just 
"doing" case management because that does not 
mean anything. Do you do it assertively or pas- 
sively? Do you do it with one person or with a 
team? Do you do it this way, or do you do it that 
way? That is what science teaches us in detail. 
The same is true with comprehensive drug abuse 
prevention strategies. 

The obverse of this is true too; simple strategies 
do not work. You need to have a comprehensive 
strategy with multiple goals to be accomplished 
simultaneously. You will hear today about norm- 
setting, alternative activities, and an entire con- 
stellation of activities, and you will have an 
opportunity to discuss the implications of trying 
to conduct more comprehensive programs. 

Next, we need to have comprehensive ap- 
proaches that involve the entire community. 
Families, schools, whole communities, and the 
media need to work together. I believe that one 
of the most effective things to happen in this 
country is the development of local antidrug coa- 
litions, and not just because they are talking to- 
gether. It is because they are getting their acts 
together. They all are working in correlated, in- 
tegrated ways and, we hope, are singing the same 
song, because another lesson from prevention 
science is that we need to get our messages 
straight. We all need to give the same messages, 
and that is very difficult. Because of different 



viewpoints about ideologies, common sense, in- 
tuition, and a number of issues, this is actually 
one of the most complex tasks. How do we get 
people to say the same thing over and over again, 
and say it in simple, understandable terms? The 
messages that we convey and the content of the 
messages are critical. Those messages have to 
be credible and based on scientific facts. 

I offer you the auspices of NID A to help provide 
those scientific facts. However, we may not abuse 
the data because when we do, we lose our cred- 
ibility. Hyperbole is useless. Children are not stu- 
pid, and they understand when you exaggerate. 
We need to give them realistic, science-based 
information. "Drugs are not good for you." You 
do not have to exaggerate. 

Long-term prevention programs have a more 
long-lasting impact on the groups most at risk 
for drug abuse. That means that longer is better, 
which seems obvious but it is not. I have been 
teasing Gil Botvin about the principle "boosters 
are better," because that is what some people hear 
when they learn about programs that give booster 
sessions over time. Let me tell you, it does not 
just mean the more exposure, the better. It means 
that one- shot programs and single exposures of- 
ten do not work. But most people want a one- 
shot program. They have a sports hero talk to 
sixth graders and say, "I did drugs. It was bad, 
and it ruined my life. Do not do it." Then they 
think they have taken care of drug prevention 
and want to move on to the next thing. It is not 
going to work. We need prolonged intervention, 
and we need to understand that the only way to 
accomplish this is through message repetition and 
emphasis, and through booster sessions. 

All of this, I hope, tells you that tremendous 
progress has been made in drug abuse science. 
We have learned a tremendous amount, but what 
I have told you is only part of the answers. The 
truth is that we do not have all the answers, and 
part of what we need from you today are the 
questions. We have brought people together not 
just to hear about drug abuse science but to talk 
about drug abuse science. We have to find out 
what people on the front line need to know to 
improve their programs and to make their efforts 
more effective. We have the power of science 
that we can bring to bear on improving preven- 
tion programs. 



Opening Plenary Session 15 



We need ways to move from the generalizations 
that I have been giving you to specifics. You will 
all receive a copy of a draft booklet that we are 
preparing. We hope it will educate you a little, 
but we want get your reactions to it as well. We 
are shaping a publication that we hope will re- 
flect the outcomes of drug abuse prevention sci- 
ence and will provide some guiding principles 
and ways to implement those principles. It is 
stamped "draft" for a reason. We want you to 
tell us what in this document works and what 
does not work for you so that we can fix it. 1 We 
have done it before, and we will do it again. We 
need to move from generalities to specifics. 
We need to find the best ways to put prevention 
science to work in our communities. 

I agree with General McCaffrey. We can get a 
handle on this country's drug abuse and addic- 
tion problem. I see it as the most complex prob- 
lem facing our society, and I believe that we need 
to develop complex strategies that acknowledge 
these problems. To do so, as General McCaffrey 
said, science has to replace ideology as the foun- 
dation for what we do. We have to acknowledge 
that the science exists. We have to pay attention 
to it, and we may have to change the way we 
do some things because this is an interactive 
process. 



Science learns in many ways, and the informing 
of science involves a two-way communication 
process. Scientists learn from people's experi- 
ences. We certainly learn the nature of the ques- 
tions to be answered from people's experiences, 
and we have to base our research agenda on your 
experiences. 

We challenge you to give us the guidance of your 
experience, not in generalities but in specifics. 
Please use some of the time that we have today 
to work together to help us set our research 
agenda. 

To get a handle on this problem, we are going to 
have to work together: the scientific community, 
prevention community, public community, and 
society at large. All of us in American society 
have to have a common commitment to prevent- 
ing drug abuse, and we have to do it in system- 
atic rather than ideological ways. I hope that this 
conference provides the kind of forum where that 
can be accomplished. If it does not, you need 
to tell us that it does not. We have brought to- 
gether a very diverse group of scientists, practi- 
tioners, and the lay community, and I hope that 
this conference becomes, in fact, a forum for 
communication. 



1 The draft booklet has since been modified, published, and disseminated as Preventing Drug Use Among Children and 
Adolescents: A Research-Based Guide, NIH Publication No. 97-4212, March 1997. 



16 National Conference on Drug Abuse Prevention Research 



PLENARY SESSION 

Risk and Protective Factor Models 

in Adolescent Drug Use: 

Putting Them to Work for Prevention 

Robert J. Pandina, Ph.D. 
Professor and Director 
Center of Alcohol Studies 
Rutgers University 



Introduction 

The importance of applying findings from risk 
factor research in the public health prevention 
sphere became apparent as a result of the suc- 
cess of the groundbreaking and landmark 
Framingham Heart Study launched in the 1960s 
(Kannel and Schatzkin, 1983). That extensive 
program sought to aid understanding of what led 
some people to be more likely than others to suf- 
fer cardiovascular disease and to apply that un- 
derstanding in the design of programs aimed at 
reducing susceptibility to various forms of car- 
diovascular disease. During the same timeframe, 
researchers in the mental health field also dem- 
onstrated the importance of factors that appeared 
to protect certain at-risk individuals from the 
development of predicted poor or negative out- 
comes. Those individuals were considered to be 
resistant or "resilient" (Rutter 1985; Garmezy 
and Masten 1994, pp. 191-208; Compas et al. 
1995, pp. 265-293). 

Risk factors are defined as ". . . those character- 
istics, variables, or hazards that, if present for a 
given individual, make it more likely that this 
individual, rather than someone selected at ran- 
dom from the general population, will develop a 
disorder" (Mrazek and Haggerty 1994, p. 127). 
Protective factors are those that, if present, make 
it less likely that such a disorder will develop. 
Resilience is based in the idea that some indi- 
viduals who are exposed to risk factors (and 
hence should be more likely to develop a disor- 
der) do not experience the disorder. Therefore, 



these otherwise susceptible individuals appear 
to be resistant to the effects of risk exposure; that 
is, they are resilient. Some investigators suggest 
that such resilience results from factors that 
buffer the at-risk individual from the adverse 
effects of exposure (Anthony and Cohler 1987). 

Risk and protective factors encompass several 
meanings or levels of explanations ranging from 
simple statistical associations with a disorder (for 
example, heart disease, mental dysfunctions, 
drug dependence), to a predisposition for devel- 
opment of (or resistance to) the disorder, to the 
actual mechanisms responsible for causing or 
preventing a disorder. Hence, risk and protec- 
tive factors can be markers (surface indicators), 
modifiers (augmenting or amplifying influences), 
or mediators (primary "causal" mechanisms) of 
drug use susceptibility and related outcomes and 
phenomena. 

These categories of factors represent varying lev- 
els of scientific certainty or specificity about the 
nature of the influence that a given factor can 
have in directly producing a risk or protective 
effect on a particular drug use outcome or sta- 
tus. For example, knowing that an individual is 
a child of an alcoholic provides a surface indica- 
tion (a marker) that a person is at heightened risk 
for negative alcohol use outcomes (for example, 
abuse and dependence). However, that marker 
designation does not specify how the risk is gen- 
erated. For example, the risk could be generated 
through genetic loading resulting in increased 



Risk and Protective Factor Models in Adolescent Drug Use 17 



receptor sensitivity to alcohol. Or the risk could 
be through a child's exposure to parental drink- 
ing models in the home environment. In this ex- 
ample, "familial history" can act as a marker, 
modifier, or mechanism. In fact, one of the im- 
portant scientific challenges in the drug abuse 
field is sorting out the nature and strength of as- 
sociations between factors known to be related 
to use statuses and outcomes and the manner in 
which factors exert their influence (Rothman 
1986; Baron and Kenny 1986; Rogosch et al. 
1990). 

Risk and Protective Factors in 
Substance Abuse Research 

Concepts related to risk and protective factors 
have been useful and effective in the design of 
programs to identify, characterize, and intervene 
in a number of serious health problems, includ- 
ing cardiovascular disease, cancer, and now drug 
abuse. Serious efforts at extending risk factor 
models to the drug abuse arena began in the early 
1980s. 

Bry and colleagues (Bry 1983; Bry and Krinsley 
1990; Bry et al. 1982, 1988, p. 301) were among 
the first to demonstrate the importance and ap- 
plicability of risk factor models in predicting drug 
use susceptibility. Their work was extended and 
refined by the work of Newcomb and colleagues 
(Newcomb 1995, pp. 7-37; Newcomb and Felix- 
Ortiz 1992; Scheier and Newcomb 1991; 
Newcomb et al. 1986). Among the important 
findings of these researchers was that the num- 
ber of risk factors appears directly related to in- 
tensity of drug use, stage in drug use, likelihood 
of escalation to more serious forms of drug use, 
risk of negative consequences, and other funda- 
mental drug use phenomena. Hence, it appeared 
that by identifying individuals with higher lev- 
els of exposure to greater numbers of risk fac- 
tors, it was possible to identify susceptible 
individuals. Research to date seems to support 
these general conclusions irrespective of age, 
gender, or ethnic considerations (see, for ex- 
ample, Brook, Cohen, et al. 1992, pp. 359-389; 
Brook, Hamburg, et al. 1992; Brook, Whiteman, 
et al. 1992; Brook et al. 1994; Brook et al., in 
press). 

Work by Newcomb illustrates the core principle 
of increasing the risk for use intensity (a basic 



drug use marker) for tobacco, alcohol, and co- 
caine. As the number of risk factors rises, the 
likelihood of heavier use increases. The rise in 
risk occurs in relationship to the number of fac- 
tors, irrespective of their nature. In other words, 
different patterns of factors can lead to the same 
level of risk. A similar result has been demon- 
strated for protective factors; that is, the larger 
the number of protective factors, the less likely 
the individual is to engage in intensive drug use. 
Specific combinations of factors seem to be less 
important than total number of factors. 

In early work, risk factors were drawn from a 
limited range of biological, psychological and 
behavioral, and social and environmental vari- 
ables thought to be related to drug use. More re- 
cent efforts (for example, Newcomb 1995; 
Pandina et al. 1992; Hancock 1996) have dra- 
matically increased the range of risk factors to 
be included and have begun an assessment of 
the interplay between risk and protective factors 
and their relative contribution to important varia- 
tions in drug use patterns and outcomes. A 
number of other key concepts emerge consist- 
ently across a wide range of studies and relate to 
the general manner in which risk and protective 
factors behave in regulating drug abuse 
susceptibility. 

The following summarizes the general charac- 
teristics of risk and protective factors: 

• They are cumulative or synergistic. 

• They differ qualitatively and quantitatively. 

• They vary in importance across individuals 
or groups. 

• They vary in influence at different times dur- 
ing the life cycle. 

• They vary in significance for the emergence 
of drug use stages and outcomes. 

• They are subject to change and can be sig- 
nificantly reduced or induced. 

The central concept is that risk and protective 
factors are cumulative in impact. Thus, the 
greater the number of risk factors, the higher 
the susceptibility. Conversely, the accumulation 
of protective factors appears to reduce risk. 
How risk and protective factors act to balance 
each other is yet to be determined. There is some 



18 National Conference on Drug Abuse Prevention Research 



preliminary information (Hancock 1996) that risk 
and protective factors may behave somewhat 
differently in influencing susceptibility. For ex- 
ample, protective factors appear to be more im- 
portant for more long-term use patterns and 
cumulative outcomes, while risk factors are more 
important for short-term, more immediate use 
patterns and outcomes. 

While some risk and protective factors appear to 
be at opposite ends of the same continuum (that 
is, high vs. low self-efficacy), therefore display- 
ing an apparently simple bipolar factor structure, 
other constructs may operate only as risk or pro- 
tective factors. Even those constructs that appear 
more straightforward (such as self-efficacy), may 
operate in different ways as risk or protective 
factors. Current research programs continue to 
enhance our understanding of the quantitative 
and qualitative characteristics of risk and pro- 
tection (Labouvie et al. 1991; Scheier and 
Newcomb 1991; Newcomb and Felix-Ortiz 
1992; Newcomb 1995). 

No single factor from any domain — biological, 
behavioral, or environmental — appears to be 
clearly and consistently identified as the single 
key factor, either risk or protective, that regu- 
lates risk susceptibility. Varying factor patterns 
may be more influential for some individuals or 
groups displaying similar characteristics. In a 
similar vein, some clusters of factors may be 
more influential in producing or limiting suscep- 
tibility for different developmental phases of the 
life cycle. Further, various stages and phases in 
the continuum of drug use behaviors and out- 
comes may be influenced differentially by dis- 
tinctive factor constellations. Thus, factors 
significant for earlier stages of use initiation (such 
as "trying" marijuana) may differ qualitatively 
and quantitatively from those related to the tran- 
sition to dependence (for example, heroin addic- 
tion or alcoholism). However, research to date 
indicates that many of these risk factors, singly 
and in combination, are related also to other dys- 
functional outcomes, such as delinquency, vio- 
lence, or serious mental disorders. In fact, it is 
not uncommon for drug-abusing individuals to 
have overlapping problems (cf. Compas et al. 
1995). 



Most significantly, research has demonstrated 
that many factors, though not necessarily all, can 
and do change across time in many individuals. 
Thus, the fact that many risk and protective fac- 
tors appear to be malleable suggests that these 
are sensitive to natural events and may be influ- 
enced by extraordinary events such as preven- 
tion interventions. It is this last important 
consideration that forms the basis of many of the 
prototypic prevention programs described by the 
prevention scientists in this volume and other 
publications (Botvin et al. 1995; Brook et al. 
1989; Dishion et al., in press; Eggert et al. 1990; 
Kumpfer et al. 1996; Donaldson et al. 1994; 
Hawkins et al. 1992; Pentz et al. 1989). 

The results of the work on the earliest models 
raised the possibility of developing a practical 
approach to identifying at-risk individuals (or 
populations of individuals at risk). The research 
also suggested that through inspection of the risk 
profiles, it might be possible to develop inter- 
vention programs aimed at decreasing levels of 
risk associated with drug use in much the same 
manner as those earlier programs aimed at car- 
diovascular disease. The most recent research 
continues to support those earliest findings and 
emphasizes the relationship, albeit complex, be- 
tween risk and protective profiles, drug use phe- 
nomena, and prevention approaches (Tobler 
1992). 

Furthermore, the most recent work linking risk 
and protective factors to drug use phenomena 
suggests a higher level of complexity than the 
initial risk factor models anticipated. Yet, the 
basic principles of the models have been retained. 
The earliest models strongly suggested the ap- 
propriateness of linking prevention efforts to our 
understanding of the way risk and protective fac- 
tors operated to influence susceptibility to drug 
use. The more refined models emphasize the need 
to base prevention programs on an understand- 
ing of risk and protective factors, including how 
they operate in different individuals at various 
stages in the life cycle, differential effects on drug 
use staging, and the extent to which they may be 
modified by specific intervention approaches. 



Risk and Protective Factor Models in Adolescent Drug Use 19 



The research community is actively investiga- 
ting a series of fundamental issues that, when 
resolved, could have major significance for pre- 
vention efforts. These include the relative im- 
portance of differential factor profiles for use 
onset and progression to more serious stages and 
problematic outcomes; the differential impact of 
factors operating at varying life cycle phases (for 
example, childhood, adolescence, young adult- 
hood, mature adulthood) (Kandel et al. 1992; 
Jessor 1993); and the degree to which factors (in- 
cluding genetic mechanisms) are sensitive to 
modification. 

Use-Behavior Continuum 

The types of use behaviors and related outcomes 
that drug abuse researchers are concerned with 
when attempting to determine degree of risk and 
protection, particularly for young people, form 
the ultimate targets for prevention science pro- 
gramming. Characterization and estimation of 
harm potential is a difficult and complex task. In 
fact, such determinations represent an important 
research effort in itself (Gable 1993). The scal- 
ing of "harm" blends together such concepts as 
risks resulting from the chemical composition 
of the substances; damage potential to biologi- 
cal targets; mechanisms of action, potency, tox- 
icity, nature, and extent of consequences; and 
other such parameters. Consideration must be 
given also to balancing exposure rates, use lev- 
els, and outcomes for various substances. Shifts 
in the ranking may be argued on the basis of 
weight given to specific factors in the harm- 
potential algorithm. Programs for youth are 
aimed primarily at blocking, reducing, or limit- 
ing involvement or intensity of drug use. 

The range of use outcomes, statuses, and condi- 
tions that prevention programs attempt to induce, 
prevent, or eliminate is summarized as follows: 

Non-use 

Use 

Misuse 

Abuse/abuser 

Problem use/user 

Dependence/dependent user 

Addiction/addict 

Recovery /recovering addict 

First- and second-degree diseases. 



The listing represents a rough qualitative con- 
tinuum ranging from less to more problematic 
outcomes, which can be obtained for all sub- 
stances (Clayton 1992). The majority of youth 
programs focus on earlier phases of the con- 
tinuum targeting induction of non-use, delay of 
use initiation, and elimination of use, misuse, and 
abuse. This is not to say that viable prevention 
programs should ignore other outcomes or sta- 
tuses; some effective campaigns focus on lim- 
ited yet well-specified behaviors, such as driving 
under the influence. However, many of the more 
serious conditions, such as addiction, are often 
remote targets of youth-oriented programs. 

Terms such as "use," "abuse," and "addiction," 
are global descriptors meant to capture quantita- 
tive and qualitative dimensions of the use- 
behavior spectrum. Use behaviors and states pos- 
sess dynamic qualities that involve processes un- 
derlying various developmental sequencing of 
stages ("acquisition" or "maintenance") and 
within stage phases ("experimentation" or "de- 
pendence") of the use spectrum. 

The following schema identifies fundamental 
developmental stages and their sequences: 

I. Acquisition 

- Priming 

- Initiation 

- Experimentation 
II. Maintenance 

- Habit formation 

- Dependence 

- Obsessive-compulsive use 
in. Control 

- Problem awareness 

- Interruption/suspension 

- Cessation. 

The stages, phases, and sequencing are applicable 
to substances typically targeted in youth-oriented 
prevention programs. Many of these programs 
focus on the acquisition and early maintenance 
features of the developmental use cycle. 

While virtually all substances share similar de- 
velopmental features, there are developmental 
features to sequencing of exposure to different 
substance classes. Kandel and colleagues 
(Kandel 1975, 1980; Yamaguchi and Kandel 
1984; Kandel et al. 1992) were among the first 



20 National Conference on Drug Abuse Prevention Research 



to demonstrate sequential ordering of substance 
use onset. For example, onset of alcohol and ciga- 
rette use precedes onset of marijuana use, which 
in turn precedes initiation of other illicit drug use. 
One consequence of these developmental aspects 
is that risk of exposure to various drugs is likely 
to occur over a relatively lengthy timespan 
ranging from early adolescence through early 
adulthood. 

Note that progression across substance classes 
is not inevitable. However, when it does occur, 
progression appears to occur in a stepwise fash- 
ion for many users. Entrance to a particular stage 
or phase of use and initiation of a particular 
substance does not mean that an individual 
cannot "regress" to an earlier stage within a par- 
ticular drug class or to an earlier position in the 
sequence between substance classes (Labouvie 
et al., in press). 

The target use behaviors forming the focus for 
prevention scientists are somewhat more com- 
plex than they might appear. Many youth- 
oriented prevention programs focus on a particu- 
lar location in the "environmental space" of the 
substance-use spectrum bounded by the earliest 
phases of use development (such as priming and 
initiation), primary "position" in the substance- 
class spectrum (such as alcohol and tobacco), and 
more global qualitative states (such as use or 
abuse). Even within these limits, the targets for 
intervention are relatively complex. 

Classes of Risk and 
Protective Factors 

Risk and protective factors can be arranged in 
three domains or classes, which, in turn, can be 
divided into relevant subclasses as follows: 

I. Biological 

- Genetic 

- Constitutional 

II. Psychological and Behavioral 

- Internal processes 

- Behavioral action profiles and repertoire 

- Interpersonal interactional styles 
III. Social and Environmental 

- Familial interactions 

- Peer interactions 

- Institutional interactions 

- Social/institutional structures. 



Biological factors can be characterized as genetic 
(related to a profile of inherited or gene- 
transcripted features) or constitutional (biologi- 
cal tissue changes induced by a variety of fac- 
tors ranging from stress to drug exposure) (Wise 
1996; Piazza and LeMoal 1996). Psychological 
and behavioral class variables include those in- 
dicative of internal processes (such as thoughts, 
feelings), behavior-action profiles and repertoires 
(drug-seeking, general deviance), and interper- 
sonal interactional styles. Social and environ- 
mental subclasses include family, peer, and 
institutional relationships. Class and domain fac- 
tors include both structural and dynamic (that is, 
process-oriented) properties. Factors within a 
given domain may be classified as simple sur- 
face markers or as factors playing a specific role 
in moderating or mediating use outcomes. One 
of the important challenges to the scientific com- 
munity is unraveling the manner in which fac- 
tors singly or in combination operate to influence 
use behavior and outcomes. 

This general structure is consistent with a living 
systems view of human drug-using behavior that 
seeks to explain drug use in terms of the interac- 
tion of biological, psychobehavioral, and envi- 
ronmental processes (Miller 1978; Ford 1987). 
Major factors in each of the domains or com- 
partments of the biopsychosocial model related 
to the substance-use continuum and related out- 
comes include the following: 

Genetic profile 

Sensory processing disturbances 

Neurocognitive alterations 

Personal history of affective disorders or im- 
pulse disorders 

Family history of alcoholism or drug abuse 

Family history of impulse disorders, such as 
conduct disorder or antisocial personality 

Family history of affective disorders 

Emotional disturbance such as depression or 
anxiety. 

These factors do not represent an exhaustive list 
of all factors identified in the literature, nor do 
they represent a "consensus taxonomy" of all 
factors. Rather, they are a representative sample 



Risk and Protective Factor Models in Adolescent Drug Use 21 



of the more accepted and documented factors in 
their most generic form. One of the most impor- 
tant and significant challenges that etiologists 
face is the development of a consensus taxonomy. 
The difficulty of the task is reflected in early and 
recent reviews of major theories of substance use 
etiology (Lettieri et al. 1980; Glantz and Pickens 
1992; Hawkins et al. 1992; Petraitis et al. 1995). 

Major biological risk and protective factors in- 
clude the following variable domains: genetic 
profiles resulting in altered brain functioning and 
hence a predisposition to, or protection from, 
substance abuse propensity; sensory processing 
disturbances or stabilities; and neurocognitive 
alterations. The risk end of the continuum may 
be marked by family history of alcoholism, drug 
abuse, or related disorders, including affective 
disorders and emotional disturbances, presence 
of impulse disorders, and presence of neuropsy- 
chological dysfunction. The range spans more 
fixed or permanent, though more labile, charac- 
teristics of the individual. 

The major behavioral/psychological risk and pro- 
tective factors include the following: 

• Personality styles, such as sensation-seeking, 
novelty-seeking, harm avoidance, or rein- 
forcement sensitivity 

Emotional profile 

Self-regulation style, such as coping reper- 
toire 

Behavioral competence 

Self-efficacy/esteem 

Positive and negative life events/experiences 

Attitudes, values, beliefs regarding drug use. 

These factors range from internal — more global 
and perhaps more stable and less malleable indi- 
vidual characteristics (such as personality pro- 
file) — to those more sensitive and reactive to 
external vectors (behavioral competence, values, 
beliefs). Factors more reactive to external forces 
may be viewed as more suitable potential tar- 
gets for intervention. 

Social/environmental risk and protection factors 
include these: 

• Structure/function of family supports 

• Parenting styles 



Opportunities for development of basic com- 
petencies 

Peer affiliations 

Economic and social (including educational) 
opportunities 

General social support structure 

Availability of prosocial activities 

Structures, including schools, communities, 
or workplaces 

Strength and influence of the faith commu- 
nity 

Social norms, attitudes, and beliefs related to 
drug use 

Availability and projected attractiveness of 
drugs and drug use 

Economic and social incentives of drug traf- 
ficking. 

As in the case of the biogenic and psycho- 
behavioral domains, factors span a range of com- 
plexity of organization. Factors may reflect the 
dynamic interactions of the individual with fam- 
ily and peer groups, with the more structured 
relationships between segments of the popula- 
tion variously characterized (for example, 
schoolchildren, dropouts, delinquents, underage 
drinkers), and with social institutions (for ex- 
ample, schools, law enforcement, regulatory 
agencies). 



Summary and Conclusions 

Risk and protective factors include biogenic, 
psychobehavioral, and socioenvironmental 
markers, modifiers, and mechanisms. These fac- 
tors vary in importance as a reflection of indi- 
vidual or group differences. Further, risk and 
protective profiles may vary in significance for 
the emergence of different use stages or out- 
comes. Similarly, the magnitude of the impact 
of specific risk and protective profiles may fluc- 
tuate during the lifespan. It appears clear that 
individual factors may be cumulative or syner- 
gistic; that is, they may combine to magnify or 
offset the negative or positive influences on the 
development of drug use and related outcomes. 
Significant for the prevention scientist is the find- 
ing that many of the most salient factors are 



22 National Conference on Drug Abuse Prevention Research 



malleable and can be successfully reduced or 
induced through a variety of external interven- 
tions (Reiss and Price 1996). Equally important 
is the finding that some factors are relatively 
stable and may not yield readily to even inten- 
sive treatments. 

A number of significant implications flow from 
the observations of etiological researchers work- 
ing to understand the interplay of risk and pro- 
tective factors. Intervention programs must 
[demonstrate understanding of] the nature of 
what they are attempting to prevent or promote. 
The design of intervention programs can profit 
substantially from consideration of the pattern 
of risk and protective factors within a given in- 
dividual, target group, community, or social in- 
stitution; and intervention strategies should be 
engineered on information derived from an un- 
derstanding of the complex interaction and op- 
eration of these risk and protective factors. 

Furthermore, intervention programs should seek 
to reduce immediate risks and promote more 
long-term protective factors in target groups or 
settings. The importance of particular risk and 
protective factors may change across groups, 
settings, and developmental periods of the 
lifespan. Hence, the general strategy for preven- 
tion efforts must encompass these facts. 

Research to date indicates the import of long- 
term commitment to intervention programs 
across childhood, adolescence, and adulthood. 
Consequently, "preventionists" need to integrate 
multicomponent, multistage programs at many 
different developmentally sensitive periods. 

Research aimed at understanding risk and pro- 
tective factors and their application to preven- 
tion efforts has to be intensified (Reiss and Price 
1996; Coie et al. 1993; Mufioz et al. 1996). The 
better we are informed about more specific pat- 
terns of factors related to use stages and outcomes 
and the way they function separately and to- 
gether, the more effectively and efficiently we 
can design and implement prevention programs. 
Information derived from research has provided 
a broad platform from which present prevention 
efforts have sprung. Intensifying our research 
efforts will provide an informed science upon 
which these pioneering and prototypic preven- 
tion efforts can advance. 



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26 National Conference on Drug Abuse Prevention Research 



Prevention Programs: What Are the 
Critical Factors That Spell Success? 



William B. Hansen, Ph.D. 

President 

Tanglewood Research, Inc. 



Introduction 

After a decade of funding dedicated to reducing 
drug use that has averaged between $1 billion 
and $1.5 billion per year, the United States is 
currently experiencing an increase in illicit drug 
use among school-age youth (Johnston et al. 
1996). This significant public investment, surely 
needed to reduce the prevalence of drug use, did 
not have the desired outcome. The challenge of 
preventing drug use will remain elusive until, as 
a society and body politic, we learn the essential 
lessons needed for success. 

Fortunately, hope is available from scientific 
research, including examples of successful pro- 
grams. Indeed, had the knowledge available to- 
day been actively applied during the past dec-ade, 
it is likely that the drug use situation would be 
different. This paper reviews the scientific prin- 
ciples of prevention that must be understood and 
applied for prevention efforts to be successful. 

Epidemiologic Trends in Use 

An epidemic of illicit drug use emerged among 
young people in the United States in the 1960s 
and continued to expand through the 1970s. 
Marijuana was the most popular illicit drug, with 
use among high school seniors gaining majority 
status. In the high school class of 1979, 60.4 per- 
cent reported having used marijuana (Johnston 
et al. 1996). Use of marijuana peaked around 
1979 or 1980, and the decade of the 1980s saw a 
consistent decline to a point where annual preva- 
lence was cut in half, going from one in two sen- 
iors in the class of 1979, to one in four seniors in 
the class of 1991. Marijuana use increased be- 
tween 1975 and 1978, when the proportion of 
seniors reporting use of marijuana on a daily or 
near-daily basis in the past 30 days rose from 



6.0 percent to an unprecedented 10.7 percent. 
Fortunately, that figure subsequently declined by 
more than 80 percent, reaching 2.0 percent in 
199 1 . Recently, there has been a substantial turn- 
around. Daily use rates were 3.6 percent in 1994 
and reveal a trend of increase that has not lev- 
eled off (Johnston et al. 1996). 

Cocaine use among high school seniors did not 
decline until after 1986. Cocaine use increased 
dramatically in the late 1970s and stayed con- 
stant among adolescents in the early 1980s. The 
early 1990s have seen neither increases nor de- 
creases in cocaine use. 

Use of inhalants generally increased throughout 
the 1990s. Among high school seniors, the an- 
nual use rate observed in 1993 was 7.0 percent, 
the highest since observations began in 1975. 
This class of drug has become the most used sub- 
stance (other than tobacco and alcohol) among 
younger students (Edwards 1993; Hansen and 
Rose 1995). Another substance that has shown 
recent signs of a reemergence is LSD (lysergic 
acid diethylamide), which had an annual preva- 
lence among 1993 high school seniors of 
6.8 percent, the highest level recorded since 1975 
(when it was 7.2 percent). Use rates increased 
for all three grades between 1991 and 1994. 
Amphetamines are yet another class of drugs that 
showed increases in use for all three grades be- 
tween 1991 and 1994. 

The decline in illicit drug use between 1980 and 
1990 has been largely attributed to the Omnibus 
Anti-Drug Act, which pumped hundreds of mil- 
lions of dollars into schools and communities to 
combat illicit drug use. However, two facts 
should be noted. First, the start of the decline in 
the use of marijuana, amphetamines, sedatives, 



Prevention Programs: Critical Factors 27 



and tobacco predated the expenditure of Federal 
funds and continued at about the same rate de- 
spite the infusion of Federal dollars. For example, 
between 1978 and 1986 (the year the Omnibus 
Anti-Drug Act was passed by Congress), the 
average rate of decline in 30-day illicit drug use 
was 1.8 percent per year. Between 1987 and 
1991, the average rate of decline increased, but 
only minimally, to 2. 1 percent per year. 

Second, the recent turnabout in the use of some 
drugs corresponded to a period of relatively high 
levels of funding, when programs, training, and 
infrastructure were in place. These considerations 
are particularly important given our understand- 
ing of the time course of drug use development. 
Among youth, the proportion of students who 
use drugs increases gradually from middle or 
junior high school, not abruptly at the 11th or 
12th grade. This suggests that the turnabout ob- 
served in high school seniors in 1992 may have 
had its beginnings several years earlier. 

There are many disturbing aspects of the recent 
trends in use of illicit drugs among students in 
the United States. Only a short time ago, it ap- 
peared that illicit drug use was on a downward 
trajectory, which was comforting for parents, 
teachers, and community leaders. The recent tra- 
jectories for a number of drugs — drugs that are 
important because of their considerable poten- 
tial for serious damage — are clearly not so com- 
forting now. This evidence suggests that funded 
efforts in schools and communities have not been 
highly effective. Because of the overall failure 
of initial efforts to produce long-term changes 
in drug use, standard practices must now be dra- 
matically improved. Models are clearly needed 
to bolster confidence that effective preventive 
practices can be identified, adopted, imple- 
mented, confirmed, and sustained. Truly effec- 
tive drug use prevention methods that are adopted 
and maintained at a significant level should be 
expected to meaningfully suppress all measures 
of drug prevalence. Our goal should be to focus 
on the adoption of scientifically grounded pre- 
ventive intervention methods that can produce a 
definable turnaround in the current trend of in- 
creasing drug use. 



Prevention 

Prevention research has focused extensively on 
three drugs: alcohol, tobacco, and marijuana. 
Cocaine has received extensive media coverage 
and is a target of interdiction by law enforce- 
ment. However, cocaine has not been targeted in 
adolescent research programs, primarily because 
its use has a relatively low prevalence among 
adolescents, and because cocaine and other 
"hard" drugs are seldom initiated without the 
earlier regular use of alcohol, tobacco, and mari- 
juana (Graham et al. 1991; Kandel 1978; Kandel 
et al. 1992). The trend of high inhalant use is too 
recent for a significant body of research to have 
emerged (Edwards 1993; Hansen and Rose 
1995). 

The goal of prevention is to delay, deter, or elimi- 
nate the onset of substance use within popula- 
tions. At the core of prevention programs are 
several assumptions that deserve consideration. 
It is now widely recognized that effective pre- 
vention programs have several common features 
(Dusenbury and Falco 1995; Hansen 1992; 
Tobler and Stratton 1997). This paper elaborates 
and comments on several of these topical fea- 
tures that are crucial to success. Features are pre- 
sented in order of importance for determining 
program success. Specifically, this review fo- 
cuses on evidence for program effectiveness 
based on program focus, delivery technique, 
evaluation, and training and support. 

Program Focus 

Program focus, the message of the program and 
what the program attempts to change, is the most 
important element of preventive intervention. 
Program focus describes how the program is sup- 
posed to work and what immediate outcome the 
program is trying to produce that will eventually 
result in a change in the onset of drug use. 

The history of prevention suggests three periods 
of program development. The first period can be 
characterized as well-intended efforts driven 
by common sense, ideology, or intuition. 
The second period is characterized as being 
theory-driven. The third period, only currently 



28 National Conference on Drug Abuse Prevention Research 



emerging, will ultimately be characterized as 
data-driven. This paper focuses on what has been 
learned from school-based efforts, primarily be- 
cause most of the published research is in this 
domain; however, the principles gleaned from 
this research should be readily applicable to other 
settings. 

Intuition-Driven Prevention 

Intuition-driven prevention programs were of- 
ten developed by individuals who had little for- 
mal training in an academic discipline but who 
viewed drug use as an issue that called for social 
action. Various approaches qualify as intuitive 
approaches. Programming efforts often focused 
on the health consequences of drug use. Having 
former addicts present their stories and describe 
the horrors of addiction was commonplace. Other 
approaches stressed understanding what drugs 
looked like, how they were injected or ingested, 
and how they were sold. By and large, intuitive 
efforts have not been evaluated. Most are not 
packaged in a manner allowing program defini- 
tion that is amenable to evaluation or research. 

Justification of these approaches often referred 
to common sense assumptions. Nearly every citi- 
zen has a ready explanation of drug use. Those 
explanations that seemed logical were the most 
likely to be adopted. For example, there is a clear 
logical connection between the fact that drug use 
is harmful and that the nature of the harm should 
be communicated. Many people viewed those 
who used drugs as having low self-esteem. The 
logical corollary of such a view was that pre- 
vention programs should focus on improving 
self-esteem. A number of good ideas have 
emerged from applying intuitive thinking to pre- 
vention; however, intuitive ideas alone do not 
always produce effective methods for interven- 
tion and can result in ideological thinking that 
may interfere with the adoption of more produc- 
tive methods. 

Intuitive methods have resulted in numerous 
commercial products. Only recently have com- 
mercially available programs been evaluated. 
Three curriculums in particular have captured a 
sizable segment of the prevention program mar- 
ket, DARE (Drug Abuse Resistance Education), 
Quest: Skills for Living, and Here's Looking at 
You, 2000. Of these, only evaluations of DARE 



have been reported in sufficient numbers to draw 
conclusions. 

The DARE program consists of materials cre- 
ated by the Los Angeles Unified School District. 
Some materials were borrowed from eclectic 
research-based programs that were developed in 
the early 1980s but were redeveloped to fit with 
an ideology consonant with police officer- 
delivery of the program; it is largely intuitive in 
its approach. The program is delivered by uni- 
formed police officers who have received exten- 
sive training at one of five regional training 
centers. DARE is delivered annually to about 
5V 2 million students in the United States. The pro- 
gram is delivered in all 50 States and has made 
international connections as well. 

The magnitude of the program notwithstanding, 
there is little evidence to support DARE as a vi- 
able or effective approach to substance abuse 
prevention. In a recent review by Ennett and col- 
leagues (1994), 17 published and unpublished 
manuscripts documenting evaluations of DARE 
were examined. Of the 17, only 11 met minimal 
standards for methodological rigor and were used 
to form the basis of interpreting findings. None 
of these studies demonstrated any outcome ef- 
fectiveness of DARE. The average calculated 
effect size reported was .06, indicating very small 
average effects. Overall, drug use among con- 
trol schools and DARE schools was roughly 
equal. Several of these studies were longitudinal 
and found neither short- nor long-term results. 
Moreover, DARE has been most heavily institu- 
tionalized since 1990, a period during which drug 
use has been escalating. 

Other packages that have been widely adopted 
include such programs as Quest: Skills for Liv- 
ing, Project Adventure, Ombudsman, BABES, 
Project CHARLIE, Children Are People, and 
Here's Looking at You, 2000. There are no ad- 
equate evaluation results by which the effective- 
ness of these programs can be judged (Thorne, 
personal communication). Evaluations that have 
been conducted have primarily been short-term 
evaluations for dissertations and theses and lack 
interpretable behavioral end points (Swisher, 
personal communication). All programs, includ- 
ing those that are intuition-driven, should be 
evaluated to determine potential effectiveness. 



Prevention Programs: Critical Factors 29 



Theory-Driven Prevention 

What distinguishes theory-driven from intuition- 
driven efforts is a reliance on a body of formal- 
ized research. Many early theory-driven 
approaches relied on research findings that, al- 
though relevant to drug use, were not the direct 
result of the application of research to drug use 
problems. Thus, social psychologists drew from 
strategies that reflected the theories of their dis- 
cipline, such as social learning theory (Bandura 
1977), much of which initially came from the 
study of aggression among children, and the 
theory of reasoned action (Ajzen and Fishbein 
1980), which initially focused on a host of so- 
cial behaviors other than drug use. Sociologists 
drew from social control theory (Hirschi 1969), 
which focused early attention on delinquent be- 
havior. Developmental psychologists focused on 
skill and competency theories (Higgins et al. 
1983) and theories that addressed affective so- 
cial development (Watson et al. 1989). Research- 
ers grounded in public health issues used the 
health belief model (Becker 1974), which origi- 
nally focused on a variety of health behaviors, 
not specifically on preventing drug use among 
adolescents. 

Beginning in the 1970s (e.g., Evans et al. 1978) 
and continuing through the 1980s, numerous 
field trials were held in which various combina- 
tions of elements were delivered and long-term 
followup tracking of behavioral effects was com- 
pleted. By and large, these field trials focused 
on programs that were theory-driven. For ex- 
ample, Evans and colleagues were the first to 
identify social perception and processes related 
to social influences and to draw from social psy- 
chological theory in the development of inter- 
vention strategies. These efforts relied on a 
combination of host-discipline theory (that is, 
theories in which the program developer was 
trained as a student) and intuition (often not ad- 
mitted) to guide program development. More- 
over, there was an open eclecticism in which bits 
and pieces of multiple theories were often as- 
sembled to create a matrix of theoretical support 
for any given intervention. 

Numerous reviews have been completed about 
the effectiveness of theory-driven curricular ap- 
proaches to prevention. These reviews have 
spanned the spectrum and have made a unique 



contribution to understanding the field of pre- 
vention. Tobacco use prevention studies have 
been extensively reviewed (e.g., Best et al. 1988; 
Botvin and Wills 1985, pp. 8-49; Evans and 
Raines 1982; Flay 1985; Leventhal and Cleary 
1980; Thompson 1978). Alcohol has been the 
focus of several reviews (Goodstadt 1980; Gor- 
don and McAlister 1982; Moskowitz 1989). Re- 
views that are specific and limited to examining 
the prevention of marijuana or cocaine use do 
not exist. However, several reviews have in- 
cluded an examination of use prevention for 
multiple substances (Bangert-Drowns 1988; Coie 
etal. 1993; Moskowitz 1989; Schapsetal. 1981; 
Tobler 1986; Tobler and Stratton 1997). 

Previous reviewers have faced the problem of 
creating a meaningful classification scheme. For 
example, Tobler (1986) examined major themes 
by researchers reporting results and proposed five 
summary program categories to describe func- 
tional content groupings: knowledge only, affec- 
tive only, peer, knowledge plus affective, and 
alternatives. 

Bangert-Drowns (1988) similarly classified pro- 
grams into three types according to functional 
content: information only, affective education 
only, or mixed. On the other hand, Coie et al. 
(1993) based their classification on theory types 
rather than program types and came up with four 
types of program components: rational, social 
reinforcement, social norm, and developmental. 
Coie and colleagues demonstrate that there is 
some similarity between their conceptualization 
of the theoretical underpinnings of prevention 
programs and those suggested by other review- 
ers (Bernstein and McAlister 1969; Thompson 
1978; Leventhal and Cleary 1980; Moskowitz 
etal. 1983;Schaps 1981). 

In other reviews, Hansen (1992), Tobler (1986), 
and Tobler and Stratton (1997) have indepen- 
dently presented categorization schemes that are 
highly similar to those presented above. Four 
functional categories of programs were identi- 
fied by each author. For Hansen (1992), classifi- 
cation schemes were based solely on program 
content. Resulting groups of curriculums in- 
cluded information and values clarification pro- 
grams, affective programs that also included 



30 National Conference on Drug Abuse Prevention Research 



information components, social influence pro- 
grams that also tended to include information, 
and multiple component programs that usually 
included some element of all three of the previ- 
ous groups but emphasized social influence in 
conjunction with additional affective strategies. 

More recently, Tobler and Stratton (1997) have 
suggested seven content areas: knowledge, af- 
fective education, refusal skills, generic skills, 
safety skills, extracurricular activities, and other 
strategies. Although this broadens the 
conceptualization of programming, little is avail- 
able about the potential of any specific program 
strategy. 

There is some intersection among these classifi- 
cation schemes. Notably, social processes, ge- 
neric skills, and knowledge often emerge as 
themes of intervention programs. Such generali- 
zations allow synthesis researchers to gain an 
understanding of the effects of general ap- 
proaches. Unfortunately, such categorizations are 
too broad to allow for a precise classification of 
programs and often obscure specific program 
elements that may be important to the design of 
prevention programs. Preventive interventions 
consist of complex sets of instructions. Broad 
categories provide few insights about what 
constitutes the effective agent of a preventive 
intervention. 

Researcher-generated programs are more often 
evaluated than commercially developed pro- 
grams, because evaluations are essential to the 
process of research-based efforts. However, un- 
til recently, the resources needed to complete 
these evaluations have been lacking. The effec- 
tiveness of school-based curricular approaches 
has been widely questioned (Moskowitz 1989). 
The primary difficulty in gaining an understand- 
ing of which strategies hold promise concerns 
methodological difficulties in conducting field 
trials to evaluate the effectiveness of these strat- 
egies. Nonetheless, two recent reviews (Hansen 
1992; Tobler and Stratton, 1997) suggest that, 
despite these difficulties, there are promising 
findings, particularly among the program types 
that include social influence approaches. 

Hansen (1992) reviewed the effects of program- 
ming on outcome variables from 45 published 



and unpublished studies. The results revealed 
positive outcomes for the following types of pro- 
grams: information, 31 percent; affective 
education, 19 percent; social influence, 51 per- 
cent; and multiple component, 50 percent. In con- 
trast, negative outcomes were found for the 
following types of programs: information, 25 per- 
cent; affective education, 19 percent; social in- 
fluence, 11 percent; and multiple component, 
zero percent. Outcomes that were neither posi- 
tive nor negative were common among all pro- 
gram categories; information programs 
(44 percent), multiple component programs 
(50 percent), and affective programs (62 percent) 
had more nonsignificant results than social 
influence programs (38 percent). 

Overall, social influence and multiple compo- 
nent programs, which also typically featured 
social influence strategies as major compo- 
nents, had more positive results than either 
information-based approaches or affective edu- 
cation approaches. This overall pattern was main- 
tained when studies with methodological 
weaknesses were deleted. Among these analy- 
ses, only 30 percent of information-based and 
42 percent of affective programs had significant 
findings as compared to 63 percent of social in- 
fluence strategies, and 72 percent of multiple 
component strategies. 

Tobler and Stratton (1997) used means and stan- 
dard deviations to calculate effect-size statistics 
for each of the studies cited above. Their review 
increased the number of studies in the analysis 
and conducted analyses on two data sets. The 
first included all reported studies for which ef- 
fect sizes could be determined. The second in- 
cluded only those studies from the larger group 
that met methodological standards for inclusion 
(adequate followup, control groups, etc.). 

Programs that were primarily informational or 
affective in nature had relatively small effect 
sizes. In contrast, programs that featured social 
influence approaches or included life skills ap- 
proaches in addition to social influence ap- 
proaches were relatively effective. Such 
programs include Project SMART (Hansen et al. 
1988), Project STAR (Pentz et al. 1989), and Life 
Skills Training (Botvin et al. 1990). 



Prevention Programs: Critical Factors 31 



Data-Driven Prevention 

More recently, researchers have systematically 
attempted the development of a science of pre- 
vention (Coie et al. 1993; Hansen and McNeal 
1996) that rests on empirical findings about eti- 
ology (Pandina, this volume). The essential dif- 
ference between data- and theory-driven 
programs is that empirical evidence about medi- 
ating variables dictates the content of interven- 
tions. Data-driven programs require that 
interventions abandon methods that address vari- 
ables that have weak statistical relationships with 
drug use. 

On the other hand, theory -based interventions do 
not exclude intervention strategies that fit with a 
theoretical model even if data supporting that 
method are not particularly strong. Data-driven 
programs ignore theory; insights from theory are 
used identically for both theory- and data-driven 
programs. As a result, theory has not been aban- 
doned, but it is second in priority to empirical 
findings. Explanation is important only once 
empirical relationships have been established. 
However, theory does not drive the selection of 
variables for intervention. 

Research on substance abuse etiology has exam- 
ined numerous variables that serve as markers 
of these concepts, and empirical findings can be 
used to demonstrate the potential of prevention 
programs to affect behavior. The essential logic 
of the etiologic approach is that a program must 
target a variable that statistically accounts for 
behavior. Variables that do not account for dif- 
ferences between users and nonusers, or between 
users and abusers, hold little promise for being 
able to influence programmatic outcomes. Fur- 
thermore, variables must be changeable. Gender, 
ethnicity, age, socioeconomic status, and basic 
personality characteristics — such as a tendency 
to take risks — are variables that often predict 
drug use. These variables are almost always con- 
sidered in program design. However, these vari- 
ables are not likely to be changed by a program 
and are therefore not the primary concern in se- 
lection of what a program is to change. 

The focus on data-driven approaches began with 
mediating variable analyses of theory -driven pro- 
grams (MacKinnon et al. 1991) and field trials 
in which tests compared programs that isolated 
specific subcomponents (Hansen and Graham 



1991; Donaldson et al. 1994). Pioneering work 
completed by MacKinnon and his colleagues 
(1991) analyzed the mediating variable paths 
through which the Midwest Prevention Project 
intervention worked. These analyses demon- 
strated that much of the effect of the tested cur- 
riculum was statistically attributable to changes 
in normative beliefs and changes in beliefs about 
consequences that were targeted by the curricu- 
lum. Several elements of the program, such as 
resistance skills, were judged to be inert because 
they lacked mediating variable significance. 

The Adolescent Alcohol Prevention Trial 
(Hansen and Graham 1991) tested the effects of 
a program that focused on establishing conven- 
tional norms and of a program that focused on 
teaching skills for resisting peer and other social 
pressures. Significant main effects were observed 
for the program that focused on normative 
education, whereas the program that focused 
on resistance skills was essentially no different 
than that for controls. Subsequent analyses 
(Donaldson et al. 1994) revealed that the resist- 
ance skills program had potential for effective- 
ness, but only when students were motivated 
from the outset to learn skills. 

It is increasingly recognized that program suc- 
cess is determined primarily by the degree to 
which programs change the characteristics of 
students, schools, neighborhoods, and families 
that statistically or mathematically account for 
changes in drug use. Two laws of program ef- 
fectiveness have recently been proposed (Hansen 
and McNeal 1996). The first, the law of indirect 
effect, posits that programs must operate by 
changing mediating variables (that is, changing 
modifiable risk and protective factors). The sec- 
ond, the law of maximum expected potential ef- 
fect, posits that only programs that target and 
change characteristics that statistically account 
for drug use have the potential to succeed. Pro- 
grams that fail to target appropriate characteris- 
tics or that target appropriate characteristics but 
fail to produce needed change cannot and will 
not succeed. 

A meta-analysis of 242 studies revealed that 1 1 
major types of variables have been examined in 
etiologic studies (Hansen et al. 1993): previous 
drug use, intentions to use drugs, cognitive fac- 
tors, competency factors, personality factors, 



32 National Conference on Drug Abuse Prevention Research 



institutional influences, drug use by others, pres- 
sures to use drugs, peer group characteristics, 
home factors, and demographics such as age, 
gender, and ethnicity. 

Drug use has long been known to be the single 
best correlate of the concurrent use of other sub- 
stances and the best predictor of future drug use 
behavior. Substance use is habitual, and many 
substances are known to be addictive, creating 
severe withdrawal [symptoms] when discontin- 
ued. However, it is important to note that factors 
other than habit and addiction account for varia- 
tions in an individual's behavior over time. 
Therefore, a primary goal of prevention should 
be to postpone and suppress drug use. 

The "drug use by others" category had a rela- 
tively strong correlation. Drug use by peers was 
more strongly correlated with self-reported drug 
use and drug use by siblings than with parental 
drug use. Beliefs about the psychological and 
social consequences of and attitudes toward drug 
use also had strong average correlations. Beliefs 
about health consequences were not as strongly 
correlated. Reported pressures to use substances, 
which included offers from peers and parents, as 
well as perceived attitudes about drug use among 
others, had large average correlations. Bonding 
and commitment to school had a strong correla- 
tion with substance use, as did deviance. 

Several categories of variables had weak rela- 
tionships with substance use. The weakest ob- 
served category of variables was home factors, 
including the psychological traits of parents, 
parent-child relationship, parental marital status, 
parental education, family composition, and so- 
cioeconomic status. These factors are different 
from parental attentiveness, parenting style, and 
parental drug use, which tended to have higher 
correlations. 

Other variable groups included institutional in- 
fluences such as church attendance and affilia- 
tion and participation in sports and other 
structured activities. A weak relationship existed 
between the substance use and competence and 
personality variables, including self-esteem, 
moodiness, and locus of control. Demographic 
variables, such as race and gender, all had aver- 
age correlations. 



Twelve Targets of 
Prevention Programs 

Research in progress (Hansen 1996a; Hansen and 
Graham [unpublished]; Hansen and McNeal 
1997) provides additional information about eti- 
ology that aids in understanding the potential of 
different programmatic approaches to prevent 
onset of drug use. The research examined 12 
mediating variables that were hypothesized to act 
as change agents in substance use prevention 
programs (Hansen 1992). 

1. Normative Beliefs — Perceptions about the 
prevalence of drug use among close friends 
and same-age peers at school and the ac- 
ceptability of substance use among friends. 
Perceptions are often exaggerated; teens 
think drug use is more prevalent and more 
acceptable than it really is. 

2. Lifestyle/Behavior Incongruence — The de- 
gree to which the student views substance 
use as incongruent with personally held cur- 
rent lifestyle and future aspirations. Teens 
who perceive their desired lifestyle as not 
fitting with drug use are hypothesized to be 
protected. 

3. Commitment — Personal commitments re- 
garding substance use. Topics include pub- 
lic statements of intentionality (for example, 
"I have signed my name somewhere to show 
that I have promised not to use drugs"). 
Items also assessed a student's private 
intentions (for example, "I have made a 
personal commitment to never smoke 
cigarettes"). 

4. Beliefs About Consequences — Beliefs about 
social, psychological, and health conse- 
quences, including being part of a group, be- 
ing less shy, doing embarrassing things in a 
group, having fun, having bad breath, hav- 
ing health problems, dealing with personal 
problems, and the probability of getting into 
trouble. 

5 . Resistance Skills — Perceived ability to iden- 
tify and resist pressure to use alcohol, to- 
bacco, and marijuana. This refers to an 
individual's ability to say "no." 



Prevention Programs: Critical Factors 33 



6. Goal-Setting Skills — Application of goal- 
setting skills and behaviors, including fre- 
quently establishing goals, developing 
strategies for achieving goals, and persis- 
tence. 

7. Decision Skills — The degree to which teens 
understand and apply a rational strategy for 
making decisions. 

8. Alternatives — Awareness of and participa- 
tion in enjoyable activities that do not in- 
volve substance use. 

9. Self- Esteem — The degree to which teens feel 
personal worth and perceive themselves to 
have characteristics that contribute to a posi- 
tive self-evaluation. 

1 0. Stress Management Skills — Perceived skills 
for coping with stress, including skills for 
relaxing as well as for confronting challeng- 
ing situations. 

11. Social Skills — Ability to establish friend- 
ships, be assertive with friends, and get 
along with others. 

12. Assistance Skills — The degree to which stu- 
dents believe they are able to give assistance 
to others who have personal problems. In- 
cluded in this concept is the ability to find 
help for oneself when experiencing personal 
difficulties. 

Mediating variables were compared on the basis 
of their ability to predict subsequent self-reported 
substance use. The variables most strongly as- 
sociated with future drug use were normative 
beliefs, values, and commitment. Moderately 
strong, but consistently less predictive, were self- 
efficacy to resist peer pressure and beliefs about 
consequences of drug use. These results, based 
on 1-year lagged correlational data collected 
from 2,639 sixth- through ninth-grade students, 
demonstrate that substance use prevention pro- 
grams that target correcting erroneous normative 
beliefs, creating a perception that substance use 
will interfere with a young person's desired 
lifestyle, and building personal commitments 
may have optimal potential for success. Because 
the magnitude of correlation is expected to be 
directly related to the potential for a program to 
result in behavior change (Hansen and McNeal 



1996), it is clear that choosing the correct set of 
mediators for intervention may have a clear pay- 
off in behavior change terms. 

An important advance that accompanies the de- 
velopment of data-driven prevention is a reliance 
on mediating variable analysis statistics to de- 
termine the reasons for program success or fail- 
ure. These statistics (MacKinnon 1994, 
pp. 127-154; MacKinnon and Dwyer 1993) al- 
low researchers to calculate the degree to which 
changes in behavior are the result of having 
changed mediators. The primary implication of 
mediating variable analysis methods is the abil- 
ity to use data about mediators and drug use out- 
comes to determine empirically how program 
effects were achieved, defining the essence of 
data-driven strategies for prevention program 
development. 

Mediating variable analysis methods can be ap- 
plied to any program as long as a mediating vari- 
able is measured. These methods were recently 
applied to understanding how the DARE pro- 
gram works (Hansen and McNeal 1997). These 
analyses demonstrate that the lack of effects of 
DARE is related to insufficient impact on the 
program elements that must be changed to pro- 
duce a preventive effect on behavior. For in- 
stance, DARE had an effect on improving the 
commitment of students, but the effect was too 
small to have a large impact on behavior. Other 
variables that are targeted by DARE, such as peer 
pressure resistance skills and normative beliefs, 
were not significantly or meaningfully changed. 

Two problems may be at the root of the lack of 
success to date of applied prevention activities. 
First, few programs target the right sets of medi- 
ating variables. Second, even among those pro- 
grams that do address variables that have a strong 
potential to mediate drug use, there is little dem- 
onstrated evidence that such programs have a 
strong impact on these variables. 

One program that was recently developed to spe- 
cifically respond to these findings has been All 
Stars (Hansen 1996Z?). This program addresses 
four mediators — building incongruence between 
desired lifestyles and high-risk behaviors, estab- 
lishing conventional norms and correcting erro- 
neous normative beliefs, building strong personal 



34 National Conference on Drug Abuse Prevention Research 



commitments to avoid high-risk behavior, and 
developing prosocial bonds. To date, only pilot- 
test data are available. Compared with students 
who received the seventh-grade DARE program, 
students who received the All Stars program had 
significantly better outcomes on each mediator. 

Conclusions About 
Program Focus 

Success in school-based drug use prevention re- 
quires the development of a significant knowl- 
edge base. Without it, preventive approaches will 
fail more often than they succeed. Currently, the 
school-based prevention field is characterized 
and dominated by individuals and groups who 
believe strongly in the value of prevention. How- 
ever, such activist approaches to prevention more 
often rely on a determination to succeed rather 
than the technical knowledge to achieve their 
goals. Unfortunately, such approaches seldom, 
if ever, achieve prevention goals. No matter how 
widespread, politically viable, or popular a pro- 
gram may be, effectiveness in preventing the 
onset of substance use and abuse must remain 
the primary and sole criterion by which programs 
are judged. 

In contrast to the state of the practice, the state 
of the art in prevention programming clearly fa- 
vors programs that are data-driven. Programs 
must target and change mediating variables that 
are strongly predictive of substance use devel- 
opment. Evidence suggests that the most prom- 
ising targets for prevention programming include 
establishing conventional normative beliefs, 
building strong personal commitments, and de- 
veloping prosocial bonds with school and other 
prosocial institutions, such as the church and the 
Boy Scouts and Girl Scouts. Other targets that 
may prove valuable include resistance skills 
training (see caveats in Hansen and Graham 1991 
and Donaldson et al. 1994), developing perceived 
incongruence between lifestyle and drug use (not 
yet tested empirically), and developing general 
competence. Given the correlations between drug 
use and delinquency, including premature sexual 
activity, prevention programs should address 
broader issues. 

Many of the approaches that have been popular 
in the past, including building self-esteem, teach- 
ing generic social skills, and teaching specific 



skills such as stress management, are not likely 
to be effective in school-based prevention. Pro- 
grams that target these characteristics may ful- 
fill other needs but are not likely to be effective 
as preventive tools. Current prevention programs 
focus on a diverse set of mediators. Programs 
can be improved by refocusing attention on 
changing variables that have the potential to 
mediate behavior. 

Delivery Technique 

Relatively little research that systematically var- 
ies the style of program delivery has been con- 
ducted. The evidence that does exist is largely 
drawn from Tobler's meta-analytic studies 
(Tobler 1986; Tobler and Stratton, 1997), which 
have examined the style of program delivery 
across many different quasi-experimental trials. 
Even though limited, the evidence is compelling. 
Tobler and Stratton (1997) present comparisons 
between programs that were judged to be inter- 
active versus those judged to be noninteractive. 
Interactive programs were those in which stu- 
dents were actively engaged through discussion, 
role-plays, and games. Noninteractive programs 
were those that relied heavily on lecture, film 
and videotape, and silent worksheet-type activi- 
ties. In seven of eight analyses in which the 
behavioral outcomes of interactive and 
noninteractive programs were compared, inter- 
active programs had significantly more overall 
effectiveness. 

These findings have an important implication for 
the design of prevention programs for students. 
Despite increasing efforts to develop interactive 
methods, teaching methods have traditionally 
relied heavily on noninteractive methods. A sig- 
nificant shift in these methods may be required 
before effective prevention can be achieved. 

Because relatively little research is available from 
randomized drug prevention studies, benchmarks 
are challenging to establish. One recent review 
of prevention programs made judgments about 
the interactiveness of programs based on an 
evaluation of written materials (Falco 1996). 
However, it clearly becomes a challenge to judge 
such programs in the abstract. Many of the pro- 
grams included in meta-analyses are completed 
under relatively good supervision. Program in- 
tegrity has been clearly linked to outcome in prior 



Prevention Programs: Critical Factors 35 



research (Rohrbach et al. 1993). Training and 
other support that can help guarantee the fidelity 
of program implementation should be given. 

A basic definition of interaction has not yet been 
developed. One might presume that one-way 
communications (preaching, lecture, film with- 
out discussion, demonstrations) are not interac- 
tive. However, it is not clear what variety of 
activities constitutes interaction. The goals of in- 
teraction are to engage participants in an active 
and positive way. Discussion can be more or less 
interactive, depending on how emotionally in- 
volved, attentive, reflective, and actively in- 
volved students become. Teaching skills through 
games and role-plays is also more likely to en- 
gage participants. 

When research is completed, some forms of in- 
teractive teaching may be preferred to others. For 
example, personal experience from Project 
SMART revealed that role-plays about peer pres- 
sure often had unintended effects. That is, role- 
players failed to resist pressure convincingly, and 
individuals assigned to play offerers often stole 
the show (Hansen, Graham, et al. 1988). 

Experience has also shown that Socratic discus- 
sions, while potentially highly interactive and 
involving, can result in undesired conclusions. 
Interactive teaching that is likely to succeed 
might well be thought of as any method that has 
the ability to engage participants in the active 
consideration of appropriate program materials, 
whether it be to develop skills or ensure active 
cognitive processing. 

It is likely that the only way for programs to 
achieve changes in mediating targeted charac- 
teristics is to require introspection within the self 
and observable "real" behaviors and attitudes 
within the peer group. Noninteractive techniques 
provide little motivation or opportunity for ei- 
ther of these to occur. 

One way interactive methods work is by requir- 
ing the individual to place personal perceptions 
and beliefs in the open for examination by oth- 
ers. For example, norm-changing programs re- 
quire students to understand what others do and 
how others feel. Such approaches require that 
students reveal personal information. Interactive 
methods often involve structured conflict that 



may also bring emotional reactions from partici- 
pants. In such circumstances, interactive meth- 
ods are much more likely to foster introspection 
and the critical examination of the attitudes, be- 
liefs, and behaviors of others. 

Interaction, by definition, is a performance vari- 
able. No matter how it is defined in a written 
curriculum, if interaction does not emerge in the 
classroom, interaction does not exist. There has 
been concern about teacher preparedness to en- 
gage in interactive methods (Bosworth and Sailes 
1993). In such circumstances, interactive tech- 
niques are of unknown potential benefit. Thus, 
although interactive methods are the only meth- 
ods for which program success is apparent, in- 
teraction remains a challenge. 

Finally, interaction alone is not expected to be a 
sufficient condition for prevention. Effective pro- 
grams are interactive, but not all interactive pro- 
grams will be effective. Programs that are highly 
involving for students but do not address the 
changing drug-related characteristics of students 
are not expected to be any more effective than 
programs that are not interactive. 

Evaluation 

To be successful, programs must demonstrate 
lower rates of substance use onset among stu- 
dents receiving the program than among students 
not receiving the program. Evaluation is crucial 
to the achievement of prevention effectiveness, 
although many programs are defended on the ba- 
sis of testimonials and subjective evaluations. 
Improving effectiveness goes hand-in-hand with 
critical program evaluation. This is true for sev- 
eral reasons. First, evaluation achieves a focus 
on end points that cannot be developed any other 
way. Second, evaluation provides information 
that can be actively incorporated into program- 
ming to guide program development and im- 
provement. Finally, without evaluation evidence, 
the ultimate effectiveness of a program simply 
cannot be known. Claims of effectiveness with- 
out data have proven misleading in the past and 
have contributed to the reemergence of drug use. 

When the Omnibus Anti-Drug Act was passed, 
the technical capability for program evalua- 
tion existed. But the technology for conducting 



36 National Conference on Drug Abuse Prevention Research 



evaluations was not disseminated broadly, and 
there was a lack of political interest in doing such 
evaluations. During the past decade, at least three 
surveys (American Drug and Alcohol Survey 
from the Rocky Mountain Behavioral Science 
Institute, the Pride Survey from PRIDE, and the 
Youth Risk Behavior Survey from the Centers 
for Disease Control) have become available to 
schools. These surveys provide valuable infor- 
mation that can be used for tracking drug use 
and mediating variables. In addition, several 
States have recently adopted Statewide needs as- 
sessment surveys, often collected through the 
schools. 

Many of these surveys contain information that 
could be used in evaluation studies. Because the 
prevalence of drug use increases among students 
as they grow older, evaluations that do not in- 
clude appropriate comparison groups will appear 
to demonstrate only that drug use is increasing. 
Several reasonable possibilities exist, including 
(1) comparing program groups with highly simi- 
lar groups (in terms of ethnicity, age, socioeco- 
nomic status, and risk for drug use) not yet 
exposed to the program; (2) comparing different 
age groups at the same outcome point, for ex- 
ample, comparing an entire grade of students who 
received a program with an entire grade of stu- 
dents who did not receive the program but at the 
same end point (e.g., ninth grade) (McNeal and 
Hansen 1995); and (3) comparing data about pro- 
gram groups that have known preprogram simi- 
larity with national data. The technology required 
to complete evaluation studies is clearly within 
reach of most social scientists. Several groups 
that offer commercial surveys are also capable 
of providing evaluation comparisons. 

A consistent recommendation is to adopt pro- 
grams that have previously been evaluated else- 
where. Although the adoption of programs that 
have been empirically validated would clearly 
be an improvement over current practice, sev- 
eral caveats about such strategies should also be 
kept in mind. Society and the research base are 
constantly changing. Published program evalu- 
ations that address behavioral outcomes typically 
involve a delay of 4 to 5 years. Dissemination 
and interest in findings may add another 2 to 
3 years. Simply adopting a program that can pass 



a strict litmus test of effectiveness may keep 
schools from ever having an effective program. 

Many of the evaluations in the literature that 
show promise today were completed by the same 
group that developed the program being evalu- 
ated. It is inevitable that some biases, either in 
program implementation or in the selection of 
findings to report, exist in this literature. 

Finally, many of the programs recently reviewed 
and given high ratings by Falco (1996) are ei- 
ther old or not commercially available. In the end, 
the capability of conducting local evaluations 
may be as viable as adopting programs shown to 
be promising through external evaluations. 

Training and Support 

The potential effectiveness of any prevention 
program is only as great as the person delivering 
the program. Bosworth and Sailes (1993) note 
that the teaching techniques used in the most 
promising prevention programs are often a chal- 
lenge for teachers to implement. Programs are 
complex and may not provide sufficient written 
background for teachers to use without training. 
Furthermore, with programs increasingly rely- 
ing on both theory- and data-based rationales for 
development, it is important to understand the 
concepts of the programs. 

Teaching has a long tradition of reinvention, and 
teachers will interpret new materials from within 
their existing framework. The promising pro- 
grams may involve a program focus and teach- 
ing style that is radically different from a 
teacher's existing paradigm. Instead of focusing 
on knowledge acquisition (the primary paradigm 
of teaching), promising programs focus on 
socialization, psychological dissonance, and 
emotion-laden topics and methods. 

Early success in program delivery appears to be 
an important determinant of ultimate mainte- 
nance of prevention programs. Teachers who find 
delivering a program too difficult may quickly 
abandon further efforts. Flannery and Torquati 
(1993) failed to find any relationship between 
school principal support and teacher participa- 
tion in training, but did find that satisfaction with 
the program was a major determinant of program 
continuance. Rohrbach and colleagues (1993) 



Prevention Programs: Critical Factors 37 



found that teachers who maintained a psychoso- 
cial prevention program beyond the first year 
were those who had higher self-efficacy, enthu- 
siasm, preparedness, teaching methods compat- 
ibility, and support from their school principals. 

Gingiss (1992) concludes that improving pro- 
gram implementation and maintenance is highly 
related to teacher training: (1) Teachers respond 
to innovations in developmental stages; (2) a 
multiphase approach to staff development is 
needed to help teachers through each stage; 
(3) continuing training is important (preservice 
training is insufficient); (4) approaches to train- 
ing should fit the skill levels of teachers; and 
(5) teacher training should be conducted in a 
manner that allows training and the implemen- 
tation of the program to maintain high visibility, 
credibility, and value. 

In support of the last recommendation, Parcel 
and coworkers (1988) postulate that institutional 
commitment, changes in policies, and establish- 
ment of appropriate roles may be prerequisites 
to the successful adoption of innovative pro- 
grams. This may include the identification of 
specialists who take on different roles within the 
school in delivering prevention programs. It may 
also require active participation by teachers in 
making decisions about program adoption (Par- 
cel et al. 1991; Paulussen et al. 1994). For ex- 
ample, some research (Perhats et al. 1996) 
suggests that teachers and parents are much more 
sensitive to the potential effectiveness of preven- 
tion programs than are principals, school board 
members, and administrative specialists. 

There has been little research on the potential 
for such strategies as continuing education to help 
improve teachers' motivation, understanding, and 
self-efficacy. However, continuing education is 
the primary source of post-inservice training that 
is available in most school districts. 

Conclusion 

The field of prevention has made significant 
progress. Science-based programs now have the 
potential to significantly reduce or, at a minimum, 
deter the onset of drug use among youth. Pro- 
grams that focus on data-driven content that is 



theoretically informed have increased the poten- 
tial strength of programming. These programs 
are highly interactive. They require training and 
support to be delivered effectively. In all cases, 
programs benefit from the adoption of evalua- 
tion methods that have the potential to document 
success and inform about failure. Local evalua- 
tion will be increasingly important in understand- 
ing the potential for programs to be effective. 

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Prevention Programs: Critical Factors 41 



Preventing Drug Abuse 
Through the Schools: 
Intervention Programs That Work 

Gilbert J. Botvin, Ph.D. 
Professor and Director 
Institute for Prevention Research 
Cornell University Medical College 



Introduction 

National survey data show that drug use among 
our Nation's youth is increasing at an alarming 
rate. Some say that we are on the verge of a ma- 
jor epidemic. However, 20 years of research have 
now provided the tools to change the current 
course of events and to reverse the increases in 
teenage drug use that began in 1992. We know 
more about the causes of drug abuse than ever 
before, and we have learned a great deal about 
what works and what does not. We are beyond 
the point where we have to make uninformed 
choices about what might prevent or reduce teen- 
age drug use. 

This paper discusses the progress in school-based 
prevention, both in general and with respect to 
the work of the author and colleagues at Cornell 
University Medical College. A major assump- 
tion in this work and a major theme of this NIDA 
conference is that prevention should be based on 
science — not on hunches, guesses, and wishful 
thinking. As General Barry McCaffrey, director 
of the Office of National Drug Control Policy, 
has said, "Ideology must be replaced by science." 

The Quest for 
Effective Approaches 

More than two decades have been devoted to try- 
ing to find effective approaches to drug abuse 
prevention. The goal of identifying effective pre- 
vention approaches has been elusive. Although 
many approaches have increased knowledge 
about the adverse consequences of using drugs 
and some have increased antidrug attitudes, few 
programs have demonstrated an impact on drug 
use behavior. However, early prevention efforts 
were based largely on "intuition" rather than on 



theory or science. As the field of drug abuse pre- 
vention has matured, there has been an increas- 
ing reliance on theory derived from empirical 
evidence of the causes of drug abuse. 

Over the past few years, prevention efforts in 
general and school-based research in particular 
have begun to bear fruit. During this time, mount- 
ing empirical evidence from a growing number 
of carefully designed and methodologically so- 
phisticated research studies clearly indicates that 
at least some approaches to drug abuse preven- 
tion work. 

The purpose of this paper is to provide a brief 
overview of what is currently known about the 
effectiveness of drug abuse prevention efforts in 
school settings. The primary focus is on ap- 
proaches that have been subjected to careful 
evaluation using acceptable scientific methods 
and whose results have been published in peer- 
reviewed journals. 

Why Conduct Drug Abuse 
Prevention in Schools? 

A variety of drug abuse prevention approaches 
have been developed and tested with different 
degrees of success. Clearly, one of the most pro- 
ductive areas of prevention research has involved 
the testing of approaches designed to be imple- 
mented in school settings. The reasons for the 
focus on school-based drug abuse prevention are 
rather obvious and straightforward. Most preven- 
tion approaches are designed to target school- 
age populations, with the greatest emphasis on 
middle/junior high school-age adolescents. 
Schools, therefore, serve as natural sites for both 
implementing and testing prevention approaches 
that target individuals in this age group. Schools 



Preventing Drug Abuse Through the Schools 43 



provide relatively easy access to a large number 
of individuals who are the logical targets of pre- 
vention efforts. Schools are also the logical site 
of prevention efforts because they offer a struc- 
tured setting within which prevention programs 
can be conducted and evaluated in a method- 
ologically rigorous way. 

Although schools are generally most concerned 
about their traditional educational mission, most 
States require that students receive tobacco, al- 
cohol, and other drug education, either alone or 
as part of a larger health education curriculum. 
Notwithstanding the fact that this may amount 
to little more than one semester during the entire 
middle/junior high school years, it frequently 
provides a natural programming slot through 
which drug abuse prevention curriculums can be 
scheduled. Educators also are gradually begin- 
ning to recognize that both health and drug abuse 
prevention are important to the achievement of 
traditional educational objectives. The problem 
of drug abuse, therefore, has come to be seen as 
both a health problem and a barrier to educa- 
tional achievement. Thus, educators have be- 
come increasingly receptive to the idea of setting 
aside some part of their academic schedule for 
drug abuse prevention. 

Building on a Solid 
Scientific Foundation 

Over the past decade and a half, drug abuse pre- 
vention studies have proceeded through several 
phases, ranging from small-scale pilot studies 
designed to test the acceptability, feasibility, and 
preliminary efficacy of promising approaches, 
to large-scale randomized field trials designed 
to provide the strongest possible evidence that a 
particular prevention method works. The most 
promising approaches have three distinguishing 
features: They are based on an understanding of 
what is known about the etiology of drug abuse, 
are conceptualized within a theoretical frame- 
work, and have been subjected to empirical test- 
ing using appropriate research methods. 
Although all three are critically important, the 
most fundamental element of any prevention pro- 
gram is an approach that is based on an under- 
standing of the etiology of drug abuse. 

The knowledge base that has developed concern- 
ing the etiology of drug abuse indicates that drug 



abuse is not caused by a single etiologic factor. 
Instead, there are many different factors that ap- 
pear to interact with one another to produce a 
complex, probabilistic risk equation. This makes 
prevention much more difficult, because instead 
of identifying a single cause and developing an 
intervention to target it, interventions must tar- 
get multiple risk and protective factors. As 
Pandina (this volume) indicates, research on the 
etiology of drug abuse suggests that to be effec- 
tive, prevention programs targeting children and 
adolescents must influence social factors as well 
as knowledge, attitudes, norms, skills, and per- 
sonality. To the extent possible, consideration 
must also be given to the importance of biologi- 
cal, pharmacological, and developmental factors. 

Information concerning the age of onset and de- 
velopmental progression from the work of 
Kandel ( 1978, pp. 3-38) and others (Hamburg et 
al. 1975) indicates that the initiation of drug use 
tends to follow a logical and predictable se- 
quence. Most individuals begin by experiment- 
ing with alcohol and tobacco, progressing later 
to the use of marijuana. All of these substances 
are widely used in our society, and not surpris- 
ingly, the progression of drug use conforms ex- 
actly to the prevalence of each substance in our 
society. Correspondingly, these substances are 
also widely and easily available, frequently in 
the home. Because of their availability, inhalants 
are also used early in this sequence. Some indi- 
viduals progress later to the use of other illicit 
substances such as stimulants, depressants, 
narcotics, and hallucinogens. This suggests that 
the focus of early prevention efforts should 
be on those substances used at the beginning of 
this sequence, that is, alcohol, tobacco, and 
marijuana. 

Conclusions drawn from epidemiology and eti- 
ology indicate that prevention interventions 
should target individuals by at least the begin- 
ning of the adolescent period (middle or junior 
high school), although how early prevention ef- 
forts should begin is as yet unclear. Another im- 
plication from the etiology literature for 
prevention is that prevention programs should 
target the gateway substances of tobacco, alco- 
hol, and marijuana. The recent increase in inhal- 
ant use and its potential role as a form of gateway 
drug use suggest that it should also be the focus 



44 National Conference on Drug Abuse Prevention Research 



of prevention efforts. These and other conclu- 
sions drawn from etiology research provide use- 
ful information concerning the kind of drug abuse 
prevention program likely to be the most effec- 
tive. Understanding the etiology of drug abuse 
also makes it easy to recognize why some pre- 
vention approaches have not succeeded. 

Prevention Approaches 
for School Settings 

Most of what is known about what works in pre- 
venting adolescent drug abuse comes from 
school-based prevention research. As indicated 
elsewhere (Botvin 1996; Botvin and Botvin 
1992), school-based prevention efforts can be 
divided into four general approaches: (1) infor- 
mation dissemination, (2) affective education, 
(3) social influence, and (4) competence enhance- 
ment. This paper focuses primarily on the last 
two approaches, because the available evidence 
indicates that they are the most promising. 

Information Dissemination 

The main staple of conventional approaches to 
drug abuse prevention has been programs de- 
signed to disseminate information about drug use, 
pharmacological effects, and the adverse conse- 
quences of drug abuse. The underlying assump- 
tion of these approaches is that the problem of 
drug abuse is caused by a lack of knowledge 
about the dangers of using drugs. Correspond- 
ingly, it is assumed that drug abuse can be pre- 
vented by making individuals aware of the 
appropriate facts about drug abuse. It is hoped 
that adolescents, armed with these facts, will 
make a logical and rational decision not to smoke, 
drink, or use illicit drugs. Closely related to in- 
formation dissemination approaches is the use 
of fear-arousal techniques or scare tactics to dra- 
matize the dangers of drug abuse and increase 
motivation to avoid drugs. 

Despite the widespread use of these approaches, 
studies testing the effectiveness of information 
dissemination or fear-arousal approaches have 
consistently shown that they do not work (Dorn 
and Thompson 1976; Goodstadt 1974; Kinder 
et al. 1980; Richards 1969; Schaps et al. 1981; 
Swisher and Hoffman 1975, pp. 49-62). These 
studies show that information dissemination ap- 
proaches are effective in their efforts to increase 



knowledge and also frequently increase antidrug 
attitudes. However, they fall short where it counts 
most — having an impact on drug use behavior. 
This is not to say that knowledge is unimportant 
or irrelevant to prevention efforts. In fact, devel- 
opmentally appropriate and personally relevant 
health information may indeed have a place in 
drug abuse prevention programs. Yet, it is clear 
that prevention approaches primarily designed 
to increase information are not effective. 

Affective Education 

Another popular approach to drug abuse preven- 
tion over the years is designed to enhance 
affective development. Affective education ap- 
proaches were widely used during the 1960s and 
early 1970s. Typically, the focus of affective edu- 
cation approaches is on increasing self-under- 
standing and -acceptance through activities such 
as values clarification and responsible 
decisionmaking; improving interpersonal rela- 
tions by fostering effective communication, peer 
counseling, and assertiveness; and increasing 
students' abilities to fulfill their basic needs 
through existing social institutions (Swisher 
1979). The results of evaluation studies testing 
affective education approaches have been as dis- 
appointing as information dissemination and 
fear-arousal approaches. Although affective edu- 
cation approaches, in some instances, have been 
able to demonstrate an impact on one or more of 
the correlates of drug use, they have not been 
able to affect behavior (Kearney and Hines 1980; 
Kim 1988). 

Social Influence 

Increases in our understanding of the etiology of 
drug abuse led to the recognition that social fac- 
tors play a major role in the initiation and early 
stages of drug use. These social influences arise 
from the media, peers, and the family. The origi- 
nal research in this area was conducted by Evans 
and colleagues (Evans 1976; Evans et al. 1978) 
and focused on adolescent cigarette smoking. The 
prevention approach developed and tested by 
Evans was a major departure from previous ap- 
proaches to tobacco, alcohol, and other drug 
abuse prevention. It is noteworthy not only be- 
cause it was the first approach to produce an 
impact on behavior, but also because it contained 
several of the core components still used in the 



Preventing Drug Abuse Through the Schools 45 



most successful drug abuse prevention ap- 
proaches, which are briefly described below. 

Psychological Inoculation 

The main emphasis of the prevention approach 
developed by Evans was a concept borrowed 
from McGuire's persuasive communications 
theory that is referred to as "psychological in- 
oculation" (McGuire 1964, pp. 192-227; 1968, 
pp. 136-314). The underlying concept is analo- 
gous to that of inoculation used in infectious dis- 
ease control. To prevent individuals from 
developing positive attitudes about smoking, 
drinking, or illicit drug use ("infection") from 
prodrug social influences ("germs"), it is neces- 
sary to expose adolescents to a weak dose of 
those germs in a way that facilitates the devel- 
opment of "antibodies" and thereby increases 
resistance to any future exposure to persuasive 
messages in a more "virulent" form. For example, 
from this perspective, cigarette smoking is con- 
ceptualized as resulting from exposure to social 
influences (persuasive messages) to smoke from 
peers and the media that are either direct (offers 
to smoke from other adolescents or cigarette ad- 
vertising) or indirect (exposure to high-status role 
models who smoke). 

Thus, a major part of the smoking prevention 
approach developed by Evans was designed to 
make students aware of the various social pres- 
sures to smoke they would likely encounter as 
they progressed through junior high school so 
they would be psychologically prepared (inocu- 
lated) to resist these influences. Although psy- 
chological inoculation was the conceptual 
centerpiece of this research, it has received less 
emphasis in more recent variations on the social 
influence model. Other components of the ap- 
proach developed by Evans have assumed greater 
importance, although in a somewhat different 
form. These include demonstrations of tech- 
niques for effectively resisting various pressures 
to smoke, periodic assessment of smoking with 
feedback to students to correct the misconcep- 
tion that smoking is a highly normative behav- 
ior, and information about the immediate 
physiological effects of smoking. 



Drug Resistance Skills 

The research conducted by Evans and colleagues 
at the end of the 1970s created a sense of excite- 
ment and optimism that had been lacking for 
many years. After a decade of disappointing and 
frustrating research, there was finally evidence 
that prevention could work. This sparked a flurry 
of research activity by other research groups in 
the United States, Canada, Europe, and Austra- 
lia. At this point, more research has been con- 
ducted with variations on the social influence 
approach to drug abuse prevention than possi- 
bly any other contemporary approach over the 
past 20 years (e.g., Arkin et al. 1981; Hurd et al. 
1980;McAlisteretal. 1979;Luepkeretal. 1983; 
Perry et al. 1983; Telch et al. 1982; Donaldson 
et al. 1994; Ellickson and Bell 1990; Snow et al. 
1992; Sussman et al. 1993). 

One of the distinct differences that emerged dur- 
ing this time was an increased emphasis on teach- 
ing what has come to be referred to as "drug 
resistance skills" or "drug refusal skills." Stu- 
dents are taught the requisite information and 
skills to recognize, avoid, or respond to high- 
risk situations — situations in which they will 
have a high likelihood of experiencing peer pres- 
sure to use drugs. Students are taught not only 
what to say in response to a peer pressure situa- 
tion (the specific content of a refusal message), 
but also how to say it in the most effective way 
possible. In addition, students are taught how to 
respond to influences from the media to use 
drugs, particularly how to resist the persuasive 
impact of advertising by recognizing the adver- 
tising appeals contained in ads and formulating 
counterarguments to those appeals. 

Correcting Normative Expectations 

Adolescents typically overestimate the preva- 
lence of smoking, drinking, and illicit drug use 
(Fishbein 1977). Therefore, the third major com- 
ponent of the social influence approach to drug 
abuse prevention involves correcting normative 
expectations, that is, correcting the misperception 
that many adults and most adolescents use drugs. 
This is sometimes referred to as "normative 



46 National Conference on Drug Abuse Prevention Research 



education" (Hansen and O'Malley 1996, pp. 161- 
192). Several methods have been used to modify 
or correct normative expectations. One method 
involves providing students with information 
concerning the prevalence rates of drug use 
among their peers either from national or local 
survey data so that they can compare their own 
estimates of drug use with actual prevalence 
rates. Another method involves having students 
participate in the prevention program to orga- 
nize and conduct classroom, schoolwide, or lo- 
cal community surveys of drug use. 

Using Peer Leaders 

A characteristic feature of many prevention ap- 
proaches based on the social influence model is 
the use of peer leaders as program providers. 
Peer leaders are selected because of their role as 
opinion leaders. They are individuals who ap- 
pear to have high credibility with the participants 
in the prevention program. They are also leaders 
in the sense that they serve, to varying degrees, 
as program providers. In most studies, peer lead- 
ers have been older students, for example, 10th 
graders might serve as peer leaders for 7th grad- 
ers; however, in some cases, peer leaders have 
been the same age as the participants and may 
even have been from the same class. The ration- 
ale for using peer leaders is that peers often have 
higher credibility with adolescents than do teach- 
ers or other adults. Peer leaders serve a variety 
of functions, including serving as discussion 
leaders, role models who do not use drugs, and 
facilitators of skills training by demonstrating the 
drug refusal skills being taught in these preven- 
tion programs. 

Competence Enhancement 
(Life Skills Training) 

Another effective drug abuse prevention ap- 
proach emphasizes teaching general personal and 
social skills, either alone (Caplan et al. 1992) or 
in combination with selected components of the 
social influence model (Botvin et al. 1980; 
Botvin and Eng 1980; Botvin, Baker, Renick et 
al. 1984; Botvin, Baker, Botvin et al. 1984; 
Botvin et al. 1983; Pentz 1983, pp. 195-232; 
Schinke and Gilchrist 1983, 1984; Gilchrist and 
Schinke 1983, pp. 125-130; Schinke 1984, pp. 
31-63; Botvin, Baker, Filazzola, and Botvin 
1990). This second approach, referred to as the 



"competence enhancement" approach, is much 
more comprehensive than the information dis- 
semination, affective education, or social influ- 
ence approaches. Moreover, unlike affective 
education approaches that rely on experiential 
classroom activities, the competence enhance- 
ment approach is based on a solid foundation of 
research and theory. 

The most extensive research on the competence 
enhancement approach to drug abuse prevention 
is the Life Skills Training program, which has 
been tested by the author's research group at 
Cornell during the past 16 years. Prior research 
on the causes of drug abuse guided the develop- 
ment of this prevention approach, and the class- 
room teaching techniques it uses are based on 
proven cognitive/behavioral skills training meth- 
ods. The theoretical foundation for the Life Skills 
Training approach is based on social learning 
theory (Bandura 1977) and problem behavior 
theory (Jessor and Jessor 1977). Drug abuse is 
conceptualized as a socially learned and func- 
tional behavior, resulting from the interaction of 
social influences that promote drug use and 
intrapersonal factors that affect susceptibility to 
these influences. 

Evidence from one study suggests that broad- 
based competence enhancement approaches may 
not be effective unless they also contain some 
resistance skills training material (Caplan et al. 
1992). This may be necessary because such ma- 
terial includes a focus on antidrug norms and 
helps students apply generic personal and social 
skills to situations related specifically to the pre- 
vention of substance abuse. Thus, the most ef- 
fective prevention approaches appear to be those 
that combine the features of the problem-specific 
social influence model and the broader compe- 
tence enhancement model. 

The primary aim of programs designed to teach 
life skills and enhance general competence is to 
teach the kinds of skills for coping with life that 
will have a relatively broad application. This 
contrasts with the social influence approach, 
which is designed to teach information, norms, 
and refusal skills with & problem-specific focus. 
Competence enhancement approaches, such 
as the Life Skills Training program, emphasize 
the application of general skills to situations di- 
rectly related to drug use and abuse, such as the 



Preventing Drug Abuse Through the Schools 47 



application of general assertive skills to situa- 
tions involving peer pressure to smoke, drink, or 
use other drugs. These same skills can be used 
for dealing with the many challenges confront- 
ing adolescents in their everyday lives, includ- 
ing but not limited to drug use. The following is 
a brief description of the content areas covered 
by the Life Skills Training program. 

Drug Resistance 
Information and Skills 

The Life Skills Training prevention model that 
the author and colleagues have tested incorpo- 
rates aspects of the social influence approach that 
are intended to deal directly with the social fac- 
tors that promote drug use. It also includes gen- 
eral self-management skills and social 
competence skills. Components from the social 
influence model include (1) teaching an aware- 
ness of social influences to use drugs, (2) cor- 
recting the misperception that everyone is using 
drugs and promoting antidrug norms, (3) teach- 
ing prevention-related information about drug 
abuse, and (4) teaching drug refusal skills. 

Self-Management Skills 

The Life Skills Training approach also involves 
teaching students a set of important skills for 
increasing independence, personal control, and 
a sense of self-mastery. This includes teaching 
students (1) general problemsolving and 
decisionmaking skills, (2) critical thinking skills 
for resisting peer and media influences, (3) skills 
for increasing self-control and self-esteem (such 
as self-appraisal, goalsetting, self-monitoring, 
and self-reinforcement), and (4) adaptive cop- 
ing strategies for relieving stress and anxiety 
through the use of cognitive coping skills or be- 
havioral relaxation techniques. 

General Social Skills 

Drug use behavior is learned through modeling 
and reinforcement and is influenced by cogni- 
tion, attitudes, and beliefs. To enhance social 
competence, students in the Life Skills Training 
program are taught a variety of general social 
skills. This includes teaching (1) skills for com- 
municating effectively (such as how to avoid 
misunderstandings by being specific, paraphras- 
ing, and asking clarifying questions), (2) skills 
for overcoming shyness, (3) skills for meeting 



new people and developing healthy friendships, 
(4) conversational skills, (5) complimenting 
skills, and (6) general assertiveness skills. These 
skills are taught through a combination of instruc- 
tion, demonstration, feedback, reinforcement, 
behavioral rehearsal (practice during class), and 
extended practice (outside of class) through be- 
havioral homework assignments from the inter- 
play of social and personal factors. 

Most of the prevention studies that have used 
this approach have focused on seventh graders. 
However, some studies have been conducted with 
6th graders (Kreutter et al. 1991), and one was 
conducted with 8th, 9th, and 10th graders (Botvin 
et al. 1980). Program length has ranged from as 
few as 7 sessions to as many as 20 sessions. Some 
of these prevention programs were conducted at 
a rate of one class session per week, whereas 
others were conducted at a rate of two or more 
classes per week. Most of the studies conducted 
so far have used adults as the primary program 
providers. In some cases these adults were teach- 
ers, and in other cases they were outside health 
professionals such as project staff members, 
graduate students, or social workers. Some stud- 
ies have included booster sessions as a means of 
preserving initial prevention effects. 

Target Population of 
Prevention Research 

Research concerning the etiology of drug abuse 
and adolescent development indicates that a criti- 
cal time for experimentation with tobacco, alco- 
hol, and illicit drugs occurs at the beginning of 
adolescence. For this reason, most of the drug 
abuse prevention research studies have involved 
middle or junior high school students. The pri- 
mary year of intervention for these studies has 
generally been the seventh grade. However, some 
studies have included students as young as fourth, 
fifth, and sixth grades (Donaldson et al. 1994; 
Shope et al. 1992; Donaldson et al. 1995; Flynn 
et al. 1992). There is general agreement that at 
least some of the risk factors for drug abuse may 
have their roots in early childhood, arguing for 
beginning interventions at a younger age. How- 
ever, a major concern of prevention researchers 
testing the efficacy of one or more intervention 
approaches is that base rates of drug use are typi- 
cally quite low prior to adolescence. 



48 National Conference on Drug Abuse Prevention Research 



To adequately test the impact of prevention pro- 
grams on drug use, it is necessary to select an 
age range that not only makes sense from an in- 
tervention perspective, but also includes indi- 
viduals who are old enough to begin using drugs 
in sufficient numbers for researchers to detect 
statistically significant differences between treat- 
ment and control groups. Generally speaking, the 
base rates of even the most prevalent forms of 
drug use are too low prior to seventh grade for 
meaningful prevention research. 

Findings From 
Evaluation Studies 

Short-Term Effects 
on Smoking 

Evaluation studies have tested the efficacy of 
drug abuse prevention approaches almost exclu- 
sively in terms of their impact on tobacco, alco- 
hol, and marijuana use, because the use of these 
substances has the highest prevalence rates and 
occurs at the beginning of the developmental 
progression of drug use. Although the largest 
number of studies have focused primarily on 
cigarette smoking, many studies have also tested 
the impact of prevention approaches on alcohol 
and marijuana use. Both the social influence and 
competence enhancement approaches have pro- 
duced impressive initial reductions in drug use 
when compared with controls, who received ei- 
ther no treatment or an alternative treatment. 

The effectiveness of social influence approaches 
has been documented in a number of studies 
(Arkin et al. 1981; Hurd et al. 1980; McAlister 
etal. 1979;Luepkeretal. 1983; Perry etal. 1983; 
Telch et al. 1982; Donaldson et al. 1994; 
Ellickson and Bell 1990; Snow et al. 1992; 
Sussman et al. 1993). The results of these stud- 
ies show a reduction in the rate of smoking by 
between 30 and 50 percent after the initial inter- 
vention. Several studies have demonstrated re- 
ductions in the overall prevalence of cigarette 
smoking among the participating students for 
both experimental smoking (less than one ciga- 
rette per week) and regular smoking (one or more 
cigarettes per week). The social influence ap- 
proach has also been found to reduce smokeless 
tobacco use (Sussman et al. 1993). 



Studies testing the efficacy of competence en- 
hancement approaches have also found signifi- 
cant reductions in cigarette smoking relative to 
controls (Botvin et al. 1980; Botvin and Eng 
1980; Botvin, Renick, Filazzola et al. 1984; 
Botvin, Baker, Botvin et al. 1984; Botvin et al. 
1983; Pentz 1983; Schinke and Gilchrist 1983, 
1984; Gilchrist and Schinke 1983, pp. 125-130; 
Schinke 1984, pp. 31-63; Botvin et al. 1990). 
These studies demonstrate that generic skills 
training approaches to drug abuse prevention can 
cut cigarette smoking from 40 to 75 percent. Data 
from two studies using the Life Skills Training 
program (Botvin and Eng 1982; Botvin et al. 
1983) show that it can reduce regular smoking 
(one or more cigarettes a week) at the 1-year 
followup evaluation by 56 to 66 percent without 
additional booster sessions. With booster ses- 
sions, these reductions have been as high as 
87 percent (Botvin et al. 1983). Moreover, ini- 
tial reductions of an equal magnitude have also 
been reported for regular smoking (Botvin et al. 
1983; Botvin and Eng 1982). 

Short-Term Effects on 
Alcohol and Marijuana Use 

Studies testing the efficacy of the social influ- 
ence approach on alcohol and marijuana use have 
reported reductions of roughly the same magni- 
tude as for cigarette smoking (Ellickson and Bell 
1990; McAlister et al. 1980; Shope et al. 1992). 
Several studies also provide evidence for the ef- 
ficacy of the competence enhancement approach 
on the use of alcohol (Botvin, Baker, Renick et 
al. 1984; Botvin, Baker, Botvin et al. 1984; Pentz 
1983, pp. 195-232; Botvin, Baker, Dusenbury et 
al. 1990; Epstein, Botvin et al. 1995) and mari- 
juana (Botvin, Baker, Botvin et al. 1984; Botvin, 
Baker, Dusenbury et al. 1990; Epstein, Botvin, 
Diaz et al. 1995). In general, prevention effects 
have been the strongest for cigarette smoking and 
marijuana use and the weakest and the most in- 
consistent across studies on alcohol use. 

Long-Term Effects 

Followup studies indicate that the prevention 
behavioral effects of these approaches have a 
reasonable degree of durability. Social influence 



Preventing Drug Abuse Through the Schools 49 



approaches have produced reductions in smok- 
ing that last for up to 4 years (Luepker et al. 1983; 
Telch et al. 1982; Sussman et al. 1993; McAlister 
et al. 1980). One multicomponent study found 
prevention effects for up to 7 years (Perry and 
Kelder 1992). However, the results of most long- 
term followup studies indicate that prevention 
effects are typically not maintained and last only 
1 or 2 years (Murray et al. 1988; Flay et al. 1989; 
Bell et al. 1993; Ellickson et al. 1993). This has 
led to concern by some that school-based pre- 
vention approaches may not be powerful enough 
to produce lasting prevention effects (Dryfoos 
1993, pp. 131-147). On the other hand, others 
have argued that the prevention approaches tested 
in these studies may have had deficiencies that 
undermined their long-term effectiveness 
(Resnicow and Botvin 1993). 

Long-term followup data (Botvin, Baker, 
Dusenbury et al. 1995) from one of the largest 
school-based substance abuse prevention stud- 
ies ever conducted found reductions in smoking, 
alcohol, and marijuana use 6 years after the ini- 
tial baseline assessment. This randomized, con- 
trolled field trial involved nearly 6,000 seventh 
graders from 56 public schools in New York 
State. After random assignment to prevention and 
control conditions, students in the prevention 
condition received the Life Skills Training pro- 
gram during the seventh grade (15 prevention 
sessions) with booster sessions in the eighth 
grade (10 sessions) and ninth grade (5 sessions). 
No intervention was provided during the 10th to 
12th grades. Followup data were collected by 
survey in class, by mail, and/or by telephone at 
the end of the 12th grade and beyond for those 
students not available for the school survey. 

The prevalence of cigarette smoking, alcohol use, 
and marijuana use for the students in the pre- 
vention condition was as much as 44 percent 
lower than for controls. Significant differences, 
up to 66 percent relative to controls, were also 
found with respect to the prevalence of polydrug 
use (i.e., students using all three gateway drugs) 
during the past week. The results of this study 
suggest that, to be effective, school-based inter- 
ventions must be more comprehensive and have 
a stronger initial dosage than most studies that 
have used the social influence approach. Preven- 
tion programs also must include at least 2 addi- 
tional years of booster intervention and be 



implemented in a manner that is faithful to the 
underlying intervention model. 

Factors Affecting 
Long-Term Effectiveness 

The failure to find long-term prevention effects 
may have to do with factors related to either the 
type of intervention tested in these studies or the 
way these interventions were implemented. The 
absence of long-term prevention effects in some 
studies should not be taken as an indictment of 
all school-based prevention programs. Accord- 
ing to Resnicow and Botvin (1993), there are 
several reasons why durable prevention effects 
may not have been produced in many long-term 
followup studies: The length of the intervention 
may have been too short (i.e., the prevention 
approach was effective, but the initial preven- 
tion "dosage" was too low to produce a long- 
term effect); booster sessions were either 
inadequate or not included (i.e., the prevention 
approach was effective, but it eroded over time 
because of the absence or inadequacy of ongo- 
ing intervention); the intervention was not imple- 
mented with enough fidelity to the intervention 
model (i.e., the correct prevention approach was 
used, but it was implemented incompletely, im- 
properly, or both); and the intervention was based 
on faulty assumptions, was incomplete, or was 
otherwise deficient (i.e., the prevention approach 
was ineffective). 

Generalizability to Minority Youth 

Most prevention research has been conducted 
with predominantly white, middle-class, subur- 
ban populations. Racial/ethnic minority youth 
have been underrepresented in prevention evalu- 
ation studies. Consequently, relatively little is 
known concerning the etiology of drug abuse 
among minority youth. However, several stud- 
ies indicate that there is substantial overlap in 
the factors promoting and maintaining drug use 
among different populations (Bettes et al. 1990; 
Botvin, Baker, Botvin et al. 1993; Botvin, 
Epstein, Schinke et al. 1994; Botvin, Goldberg, 
Botvin et al. 1993; Epstein et al. 1994). This sug- 
gests that prevention approaches found to be ef- 
fective with one population should also be 
effective with others. Over the past decade, this 
hypothesis has been investigated in a number 
of studies that tested the generalizability of 



50 National Conference on Drug Abuse Prevention Research 



prevention approaches previously found to be ef- 
fective with white youth. 

Studies testing the efficacy of Life Skills Train- 
ing have shown that it is effective in decreasing 
drug use, intentions to use drugs, and risk fac- 
tors associated with drug use. Qualitative re- 
search with parents, teachers, and students found 
high acceptance and perceived utility for this 
prevention approach among black and Hispanic 
populations. Where appropriate, the language, 
examples, and behavior rehearsal scenarios were 
modified to increase cultural sensitivity and rel- 
evance to each of the target populations, but no 
modifications were made to the underlying pre- 
vention approach that focused on teaching ge- 
neric personal and social skills, anti-drug-use 
norms, drug refusal skills, and prevention-related 
knowledge and information. 

To date, most of the research with minority youth 
has involved cigarette smoking. These studies 
have consistently shown that the Life Skills 
Training approach can result in less cigarette 
smoking relative to controls for inner-city His- 
panic youth (Botvin, Dusenbury, Baker et al. 
1989; Botvin et al. 1992) and African- American 
youth (Botvin, Batson, Witts-Vitale et al. 1989; 
Botvin and Cardwell 1992). Followup data with 
Hispanic youth have demonstrated the contin- 
ued presence of lower levels of cigarette smok- 
ing up to the end of the 10th grade (Botvin, 
Schinke, Epstein, and Diaz 1994). Several re- 
cent studies show that drug abuse prevention 
approaches such as Life Skills Training can also 
reduce alcohol and marijuana use among minor- 
ity populations (Botvin, Schinke, Epstein, and 
Diaz 1994; Botvin, Schinke et al. 1995), and that 
tailoring the intervention to the culture of the 
target population can enhance its effectiveness 
(Botvin, Schinke et al. 1995). 

Program Providers 

Considerable variation exists among the indi- 
viduals responsible for implementing school- 
based drug abuse prevention programs. Some 
programs have been implemented by college stu- 
dents, others by members of the research project 
staff, and still others have used classroom teach- 
ers to implement the prevention programs. It has 
generally been assumed that peer leaders play 
an important role in social influence approaches. 



Same-age or older peer leaders have been in- 
cluded in nearly all of the studies testing social 
influence approaches and in some of the studies 
testing the personal and social skills training ap- 
proaches (competence enhancement). In general, 
evidence supports the use of peer leaders for this 
type of prevention strategy (Arkin et al. 1981; 
Perry et al. 1983). 

Although peer leaders have been used success- 
fully to varying degrees in these programs, they 
usually assist adult program providers and have 
specific and well-defined roles. The primary pro- 
viders in most of these studies have been either 
members of the research project staff or teach- 
ers. There is also evidence to suggest that peer- 
led programs may not be uniformly effective for 
all students. For example, the results of one study 
suggest that although boys and girls may be 
equally affected by social influence programs 
conducted by teachers, girls may be more influ- 
enced by peer-led programs than are boys (Fisher 
et al. 1983). 

Research studies with competence enhancement 
approaches have shown that they can be success- 
fully implemented by project staff members, peer 
leaders, and classroom teachers (Botvin and 
Botvin 1992); however, not all adult program 
providers are equally effective (Botvin, Baker, 
Filazzola et al. 1990). Additional research is 
needed to identify the characteristics of the most 
effective providers as well as the optimal match 
between the characteristics of providers and pre- 
vention program participants. 

Project DARE (Drug Abuse Resistance Educa- 
tion), which is conducted by police officers, is 
on the other end of the program provider spec- 
trum from programs using peer leaders. DARE 
is without a doubt one of the best known appli- 
cations of the social influence model. Project 
DARE was initially developed by the Los Ange- 
les Police Department and based on research 
conducted at the University of Southern Califor- 
nia. The fact that it has been embraced by police 
departments throughout the country has provided 
a natural dissemination system unparalleled by 
other prevention programs. Being a prevention 
program that is implemented by police officers 
and supported by law enforcement agencies 
around the country makes DARE unique and has 



Preventing Drug Abuse Through the Schools 51 



no doubt contributed to its adoption by a large 
number of schools. According to news accounts, 
DARE is said to be used in approximately 
60 percent of the elementary school classrooms 
in America. 

Yet, despite its acknowledged success in promot- 
ing awareness of drug abuse and gaining adop- 
tion by more schools across the country than any 
other program, DARE has been plagued by dis- 
appointing evaluation results and a surprising 
amount of negative news coverage. According 
to a major meta-analysis of studies evaluating 
the DARE program, it is less effective than other 
social influence approaches and has produced 
only minimal effects on drug use behavior 
(Ennett et al. 1994). Because DARE has much 
in common with other prevention approaches 
based on the social influence model, its poor 
evaluation results are difficult to explain. In view 
of the fact that the main difference between simi- 
lar programs showing reductions in drug use and 
DARE is the program provider, a logical con- 
clusion is that the absence of strong prevention 
effects may be related more to the program pro- 
vider than the program itself. The rationale for 
using peer leaders as program providers has been 
that peers have greater credibility regarding 
lifestyle issues than parents, teachers, or other 
adults who are viewed as authority figures. This 
is especially true during a developmental period 
when individuals, particularly those who are at 
greatest risk for engaging in deviant behaviors, 
are increasingly likely to rebel against authority 
figures. Because a police officer is the ultimate 
symbol of authority in our society, it is reason- 
able to expect them to have lower credibility with 
high-risk children and adolescents and, corre- 
spondingly, to be less effective as a drug abuse 
prevention program provider. Still, the effective- 
ness of police officers as program providers has 
not been directly tested, so it remains an open 
question in need of empirical clarification. 

Summary and Conclusion 

This chapter has focused on drug abuse preven- 
tion efforts in school settings. Schools are a natu- 
ral and convenient site for conducting drug abuse 
prevention programs. Increasingly, educators are 
coming to recognize that promoting health and 
preventing drug abuse are vitally important both 



to the general well-being of students and to the 
achievement of primary educational objectives. 
When the standard of effectiveness is deterrence 
of drug use, prevention approaches that rely on 
providing students with information about the 
adverse consequences of using drugs have been 
consistently found to be ineffective. Similarly, 
efforts to promote affective development through 
unfocused, experiential activities have also been 
found ineffective. 

The only prevention approaches that have been 
demonstrated to effectively reduce drug use be- 
havior are those that teach junior high school stu- 
dents social resistance skills and antidrug norms, 
either alone or in combination with teaching ge- 
neric personal and social skills. Both approaches 
emphasize skills training and deemphasize the 
provision of information concerning the adverse 
health consequences of drug use. These ap- 
proaches have been shown to work with differ- 
ent program providers and different target 
populations, including racial/ethnic minority 
youth. Despite generally impressive initial pre- 
vention effects, it is evident that without booster 
sessions, these effects decay over time. Thus, to 
produce lasting prevention effects, it is neces- 
sary to have ongoing prevention activities 
throughout the early adolescent years and per- 
haps until the end of high school. 

The field of drug abuse prevention has advanced 
considerably in the past decade and a half. Yet, 
despite the promise offered by existing school- 
based approaches, additional research is needed 
to further refine current prevention models to 
optimize their effectiveness and increase our 
understanding of how they work. However, for 
the first time in the history of drug abuse pre- 
vention, evidence from a number of rigorously 
designed evaluation studies shows that specific 
school-based prevention models are effective. It 
is now incumbent on health care professionals, 
educators, community leaders, and policymakers 
to move expeditiously toward wide dissemina- 
tion and utilization of these approaches. It is 
equally important for private and governmental 
agencies to provide adequate funding for the 
important research necessary to further refine 
existing prevention models and to increase our 
understanding of the causes of substance abuse. 



52 National Conference on Drug Abuse Prevention Research 



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56 National Conference on Drug Abuse Prevention Research 



Invited Paper 

Reconnecting Youth: 

An Indicated Prevention Program 

Leona L Eggert, Ph.D., R.N. 

Reconnecting At-Risk Youth Prevention Research Program 
Psychosocial and Community Health Department, School of Nursing 
University of Washington 



Introduction 

This paper reflects the past 12 years of exten- 
sive work by the Reconnecting At-Risk Youth 
Prevention research team. Much of this material 
has been synthesized from Reconnecting Youth: 
A Peer Group Approach to Building Life Skills 
(Eggert, Nicholas, and Owen 1995). This work 
has involved more than 2,000 youth, both high- 
risk and typical high school students. After four 
program evaluations, the author and colleagues 
have demonstrated that prevention can work. The 
Reconnecting Youth program was proven effec- 
tive in helping high-risk youth improve their 
achievement in school, reduce their drug involve- 
ment, manage their depression and/or aggression, 
and decrease their suicidal behaviors. In addi- 
tion, the results show that improvement in per- 
sonal control and school bonding occurred 
(Eggert, Thompson, et al. 1995; Eggert et al., 
Preventing adolescent, 1994; Thompson 
et al., n.d.). 

This paper, which details Reconnecting Youth 
as an indicated (see below) prevention program, 
is directed to professional school personnel — 
teachers, counselors, school nurses, and other 
human service professionals — who work directly 
with high-risk youth. It also speaks to 
policymakers — principals, administrators, school 
board members, and legislators — whose job it is 
to select effective programs for high school drop- 
out and drug prevention programs. 

This paper addresses what is meant by indicated 
prevention and then describes what has been 
learned from high-risk youth in schools. This 
information provides a profile of the students for 
whom Reconnecting Youth was designed. The 
paper also includes a brief synopsis of the pre- 
vention goals, key elements, unique features, and 



theoretic framework of the Reconnecting Youth 
program. The core program element, the Personal 
Growth Class, is detailed and followed by a dis- 
cussion of issues to be considered before adop- 
tion and implementation of the program. The 
paper concludes with evidence of how and why 
the program helps high-risk youth achieve the 
program goals and enhance their personal and 
social protective factors. 

The goals of this paper are to provide 

• An understanding of what indicated preven- 
tion programs are and what makes Reconnect- 
ing Youth a model of such programs 

• A broader understanding of what was learned 
about high-risk youth's disconnections, vul- 
nerabilities, and strengths and how this knowl- 
edge informed the overall structure, activities, 
and implementation processes in Reconnect- 
ing Youth 

• A grasp of the key features of Reconnecting 
Youth — how it works and the evidence sup- 
porting its effectiveness 

• Guidance for those who may be considering 
implementation of Reconnecting Youth 

• A commitment to consider initiating or sup- 
porting school-based indicated prevention 
efforts. 

Indicated Prevention: 
What It Means 

Prevention is defined as either a strategy that 
reduces the likelihood of health problems ever 
occurring or a process that stems the progres- 
sion of a health problem from early warning signs 
to a diagnosable disease or disorder. A preven- 
tion program is a set of coordinated approaches 



Reconnecting Youth 57 



regarded as necessary to counteract the multiple 
factors involved in attempting to reduce adoles- 
cent problem behaviors. 

A New Public Health 
Model of Prevention 

Prevention approaches traditionally were defined 
as primary, secondary, and tertiary. Gordon 
(1987, pp. 20-26) proposed a more precise, less 
confusing prevention scheme that was adapted 
by the Institute of Medicine (1994). This new 
model includes a continuum of universal, selec- 
tive, and indicated prevention approaches. Each 
type of prevention intervention has a different 
focus and mission. When applied to the preven- 
tion of drug use/abuse in schools, the key points 
are as follows: 

• Universal prevention programs benefit every- 
one in the school by providing needed educa- 
tion. The overall mission is to keep students 
from ever initiating drug use and to keep the 
school community drug-free. 

• Selective prevention programs benefit known 
at-risk groups. One implication is that these 
groups must be identified for the delivery of 
prevention efforts (Kumpfer and Alvarado 
1997). The overall mission is to impede the 
onset of drug use in known at-risk groups. 

• Indicated prevention programs benefit iden- 
tified high-risk individuals who already show 
signs of drug involvement (Eggert et al., Pre- 
venting adolescent, 1994; A prevention, 1994; 
Powell-Cope and Eggert 1994, pp. 23-51). 
The mission of indicated prevention is to stem 
the progression and reduce the frequency of 
drug use among these youth. The school popu- 
lation must be screened in order to find the 
individuals who are at risk to provide them 
with a suitable prevention program. 

Universal prevention programs are insufficient 
as vulnerability to drug use increases to higher 
risk levels (Institute of Medicine 1994). When 
there are increasing numbers of risk factors and 
diminishing protective factors operating in a 
youth's life, a prevention program that is more 
comprehensive and of greater duration is re- 
quired. An important principle, however, is that 
indicated prevention programs on a compre- 
hensive level are not necessary for most youth. 



Unlike universal prevention programs, where all 
students in a school or classroom receive the pre- 
vention intervention, indicated prevention pro- 
grams are best reserved for those in greatest need, 
such as those already involved with drugs. In ad- 
dition, indicated prevention programs require an 
understanding and assessment of a student's risk 
and protective factors related to drug abuse. To 
be most effective, the prevention program is de- 
signed to directly influence these individual risk 
and protective factors. 

Reconnecting Youth fits the definition of an in- 
dicated prevention program for particular high- 
risk individuals; that is, those on a high school 
dropout trajectory. This is because the intended 
participants demonstrate increased vulnerability 
to both drug involvement and suicide risk. These 
are students in need of a stronger "dose" of pre- 
vention interventions. 

Characteristics of 
High-Risk Youth 

The author and coworkers conducted a series of 
descriptive ethnographic and survey studies to 
enhance their understanding of high-risk youth. 
Identifying causal risk factors and their linkage 
to school dropout were critical challenges in the 
beginning. Accurately identifying the youth 
thought to be at highest risk of school dropout 
was another. 

In repeated studies, the vulnerabilities for high- 
risk youth (Eggert and Herting 1993; Eggert and 
Nicholas 1992; Thompson et al. 1994) pointed 
to significant differences between high-risk youth 
and "typical" high school students. High-risk 
youth had more negative school experiences, 
greater drug involvement, more emotional dis- 
tress (anger, depression, stress, suicidal behav- 
iors), more deviant peer bonding, greater family 
strain, and less social support provided by school 
teachers, and other special persons in their so- 
cial networks. The factors exerting the greatest 
negative influences on adolescent drug involve- 
ment included school strain, family strain, and 
deviant peer bonding (Randell et al., in press). 
Key predictors of suicide ideation included de- 
pression, drug involvement, family distress, and 
the likelihood of dropout (Thompson et al. 1994). 



58 National Conference on Drug Abuse Prevention Research 



The following accounts are from high-risk youth 
(Eggert 1996/?). They represent approximately 
25 percent of the Nation's youth and 7 million 
of those age 10 to 17 years. Their growing num- 
bers in high schools and the challenges they 
present were the motivating factors for determin- 
ing the requirements of an indicated prevention 
program. 

For many high-risk youth, negative school ex- 
periences are longstanding: 

"School has always been awful for me. I 
totally hate it. I'm always getting Fs and I 
hate that! The pressures at school don 't 
ever stop! If you want to know the truth, I 
think a lot about dropping out. People are 
always picking on me and I always feel 
stupid. " (lOth-grade male) 

"I've always been a social outcast at 
school, I've never had friends here. I don 't 
know why. Maybe it's because I'm not 
pretty or anything. I don 't know how to 
meet people . . . . I can do it when we 're 
smoking and if I get stoned, but then they 
take advantage of you. " (9th-grade female) 

Drug involvement, by the students' own admis- 
sion, hurts more than it helps and is out of con- 
trol for high-risk youth: 

"So many people in high school are using 
drugs. Most athletes and smart people only 
drink alcohol, but many kids do all sorts 
of drugs. The people who come to school 
stoned or drunk every day are in their own 
world. It's sad, because up until adulthood 
we are so vulnerable, and are just figur- 
ing out who we are and what talents and 
qualities we have. And when people put 
you down and don 't encourage you, then 
you don 't believe in yourself. " (1 2th-grade 
male) 

"Drugs helped me and they hurt me. Those 
times I couldn 't handle all the stress, they 
helped me escape from the pressure. But 
in the long run drugs hurt me more than 
helped me. I kept using more and more and 
now it 's out of control. I use to escape from 
everything. Now, I'm trying to stop, but I 
can't. " (llth-grade female) 



Drug involvement and poor school experiences 
are linked with depression and suicidal behav- 
iors. In their own words, youth make these 
connections: 

"Drugs just get you deeper and deeper into 
depression until the hole gets so deep you 
can 't see out. When all you know is drugs, 
when all you do is to be deceitful and ma- 
nipulative, when that's all you do, it's hard 
. . . it 's hard to stop doing it." (11 th-grade 
female) 

"Shortly after I quit school I tried to kill 
myself. I felt very lonely and afraid of what 
was happening to me. Sometimes I felt 
completely separate from everybody else, 
and I started to wonder if genetically some- 
thing was wrong with me. Maybe the abil- 
ity to feel good had somehow been left out 
of me, or eliminated totally somehow .... 
/ knew I couldn 't keep facing the pain, the 

fear I'd either go crazy or die. " ( 1 2th- 

grade male) 

Problems with peers and parents are also com- 
mon. Characteristic of more than two-thirds of 
the youth, negative peer influences, family dis- 
tress, and social disorganization, are illustrated 
below: 

"My friends . . . we are helping each other 
because none of us like our parents. Most 
of us have run away before . . . we man- 
age! " (9th-grade female) 

"It's been really rough right now. My girl- 
friend is 16. She has mass family problems 
. . . and her problems are totally over- 
whelming for her and for me. It's like a 
never-ending depression." (12th-grade 
male) 

"My parents are splitting up, you know, 
getting divorced. My father used to beat 
up my mother and stuff and now there's a 
court order saying he can 't come near any 
of us. There 's more stress at home than I 
can manage. I 'm the oldest, and right now 
everyone is totally out of control. We 're 
stealing from each other and from our 
mother, and everyone is fighting and yell- 
ing. " ( 1 1 th-grade female) 



Reconnecting Youth 59 



Overview of the 
Reconnecting Youth 
Indicated Prevention 
Program 

Achieving the central aims of Reconnecting 
Youth meant (1) targeting potential dropouts, one 
of the most elusive and highest risk groups; 
(2) testing theory-based interventions that focus 
on the multiple risk factors and supporting the 
assets of these high-risk students; and (3) inte- 
grating these interventions into high schools 
whose culture is not necessarily friendly toward 
research. 

The Program Goals 

Risk reduction and resiliency enhancement 
(Hawkins et al. 1992) are key objectives used in 
achieving the indicated prevention program goals 
in Reconnecting Youth (Eggert, Nicholas, and 
Owen 1995). This means focusing strategies on 
the individual or environmental risk factors 
linked with the co-occurring problem behaviors 
of poor school performance, drug involvement, 
and suicide risk behaviors. The program has the 
following three central risk-reduction goals: 

1. Decreased school deviance — reflected by 
decreased truancy, increased GPA (grade point 
average) across all classes, and increased 
credits earned toward graduation 

2. Decreased drug involvement — reflected by 
decreased frequency of alcohol and other drug 
use, drug use control problems, and adverse 
drug use consequences 

3. Decreased emotional distress — reflected by 
decreased depression, aggression, and suicidal 
behaviors. 

Specific risk-reduction objectives that support 
these goals include: 

• To change personal risk factors such as im- 
pulsive decisionmaking and actions through 
skills training in personal control strategies 
and interpersonal communication 

• To decrease related interpersonal and school 
risk factors (primarily deviant peer bonding 
and lack of school bonding) through enhanc- 
ing positive peer-group support and teacher 
support. 



Specific objectives that focus on enhancing re- 
siliency include the following: 

• To increase the youths' personal resources, 
including enhancing a strong sense of self- 
worth, a belief in one's ability to handle life's 
problems, and a positive view of the future 
(personal protective factors) (Powell-Cope 
and Eggert 1994, pp. 23-51) 

• To change social or environmental protective 
factors, including surrounding the youth with 
a network of caring and supportive friends and 
family, and enhancing positive school expe- 
riences and social support from favorite teach- 
ers (Powell-Cope and Eggert 1994, pp. 23-5 1 ; 
Eggert et al., A measure, 1994), from the 
school, and from parents. 

The objectives are aimed at reducing risks and 
enhancing resiliency, not just for the youth but 
also for their networks of close friends, family, 
school, and community (Eggert and Parks 1987; 
Hansen 1992; Hawkins et al. 1992). Focusing 
on both risk and protective factors enhances de- 
creased drug involvement (Eggert and Herting 
1991; Eggert etal. 1990; Eggert etal., A preven- 
tion, 1994; Eggert et al., Preventing adolescent, 
1994) and reduced suicide potential (Eggert et 
al., Reducing suicide, 1995). 

Theoretic Framework 

The framework for Reconnecting Youth is a 
social-network-support model (Eggert 1987, 
pp. 80-104; Eggert and Herting 1991). This 
framework explicitly embodies the idea that any 
student's drug involvement and school perfor- 
mance develop and are maintained within a so- 
cial context. If change in these behaviors is 
desired, interventions must occur and take into 
account this social context. In Reconnecting 
Youth, this context comprises a social network 
component (the school community, including the 
students' parents or guardians); the social sup- 
port processes (the relations between the key in- 
dividuals within the social network); and the 
desired outcomes (increased school performance, 
reduced drug involvement, and decreased emo- 
tional distress). 

Especially important for bringing about change 
are the social support processes, including school 
network relations, family relations, and the 



60 National Conference on Drug Abuse Prevention Research 



teacher-student and peer-to-peer interpersonal 
relationship ties. Through these interpersonal 
relationships, the social support is delivered and 
received by the students. This social support is 
characterized by "expressive support," in terms 
of acceptance and belonging, and "instrumental 
support," in terms of skills training. Expressive 
and instrumental support motivate and influence 
changes toward program goal achievement. 

Reconnecting Youth is designed to be high 
school-based and is grounded in a partnership 
model among youth, parents, school personnel, 
and prevention practitioners in the community. 

The program is unique in several important ways, 
including the following: 

• It is a comprehensive and sustained indicated 
prevention program. 

• It has a psychoeducational framework that 
integrates small-group work and life skills 
training within a social network support sys- 
tem. 

• It is delivered by trained school teachers ca- 
pable of creating a sustaining positive peer- 
group support to counteract negative peer 
influences on truancy and using drugs. 

• It is expressly designed to modify risk fac- 
tors linked with adolescent drug involvement 
such as truancy, poor school performance, de- 
pression, aggression, suicidal behaviors, and 
deviant peer bonding. 

• It is expressly designed to enhance personal 
and social protective factors such as self- 
esteem, personal control, school bonding, and 
family support. 

• It is grounded in a partnership model among 
students, school personnel, parents, and pre- 
vention practitioners/researchers. 

Reconnecting Youth is designed to reach high- 
risk youth who are not having a successful school 
experience. The intended participants are poten- 
tial school dropouts in grades 9 through 12. Stu- 
dents identified as potential school dropouts are 
invited to participate in the program. The mes- 
sage is a strong appeal to join; it is an invitation 
to "drop into school" rather than dropping 
out. From the outset, the students are motivated 
and encouraged to benefit from the program in 



specific ways — at school, at work, with friends, 
and at home — by developing a greater sense of 
personal control, supportive communication 
skills, adaptive coping behaviors, and improved 
interpersonal relationship skills. In other words, 
they can belong and help themselves and others 
succeed at school. 

Reconnecting Youth integrates four key elements 
into the school environment. 

1 . The Personal Growth Class (PGC) — The core 
element, PGC is structured as an elective 
course in the overall curriculum. It is con- 
ducted in daily, hour-long class sessions dur- 
ing regular school hours for a full semester 
(typically 90 days). An optional second se- 
mester program is currently being tested for 
its efficacy in preventing relapse and promot- 
ing continued growth. PGC is taught by spe- 
cially selected and trained high school 
teachers (or another school-based staff mem- 
ber such as a counselor, nurse, or psycholo- 
gist). The teacher-to-student ratio is 1:10 to 
1:12. 

2. School Bonding Activities Component — This 
element focuses on social, recreational, and 
school activities. Interventions are designed 
to reconnect students to school- and health- 
promoting activities that address a student's 
need for fun activities as an alternative to drug 
involvement, loneliness, or depression. 

3. Parent Involvement Component — Parents are 
important partners in Reconnecting Youth. 
They are essential for providing support at 
home for day-to-day life skills learned in 
PGC. The PGC teacher contacts parents to 
take the first step in establishing the partner- 
ship relationship and to enlist their support in 
helping their child make important changes 
by reinforcing the program goals in appro- 
priate ways at home. Currently, a separate 
Parents as Partners intervention component 
is being tested for its efficacy in enhancing 
the effectiveness of PGC (Eggert 1996a). 

4. School Crisis Response System — A school- 
based crisis response plan was established 
because of the feelings of depression and 
suicidal behaviors evidenced by many of 
the high-risk youth. This element provides 



Reconnecting Youth 61 



guidelines for classroom teachers and other 
school personnel for recognizing the warn- 
ing signs and helping suicidal youth. 

The school activities component, parent involve- 
ment, and crisis response plan all foster the de- 
velopment of a schoolwide network of support. 
These elements help the high-risk youth sustain 
the desired behavioral changes fostered in PGC 
and apply them at school and at home. 

The Personal Growth Class Model 

The PGC component is grounded in a psycho- 
educational model. It is unique in that it adapts 
and integrates the following previously tested 
approaches: 

1 . A peer-group counseling model designed to 
intervene with delinquent youth (Positive 
Peer Culture by Vorrath and Brendtro 1995). 

2. An adolescent life skills training approach 
(Life Skills Counseling With Adolescents by 
Schinke and Gilchrist 1984). 

Group work and skills training are vitally linked. 
Skills developed in four areas are applied to the 
three program goals within a positive group con- 
text (see figure 1). Through this positive group 
experience, students give and receive support in 
the form of acceptance and caring. They also help 



each other with life skills training applied to their 
personal issues. 

The Group Work Submodel 

Central to the effectiveness of PGC is a positive 
group experience, because social support is the 
motivating force for behavior change. The aim 
is to provide each youth with support from the 
leader and other PGC participants, making so- 
cialization a positive experience. Group work is 
characterized by group belonging and acceptance 
for all members and a heavy dose of expressed 
support and help from the leader and all group 
members. 

A positive peer group is the key to the success 
of PGC. The group leader fosters the develop- 
ment of the positive peer-group culture by con- 
sistently demonstrating or modeling care and 
concern in interactions with the group and with 
each student. In this way, the group members 
learn to care about each other, and a climate for 
the desired behavioral changes is established. 

The group leader is the "heartbeat" of the pro- 
gram, establishing group norms that reflect care 
and concern. During the invitation process and 
throughout the group sessions, it is the leader's 
task to ensure that each student feels welcomed, 



1 . Self-Esteem Enhancement (SE) 



Use skills for appreciating self (positive 
self-talk, positive actions). 
Support positive self-esteem in others. 
Apply SE skills to program goals. 



3. Personal Control (PC) 



Attend to stressors and stress 

responses. 

Use healthy coping strategies for 

handling stress, anger, and depression. 

Apply PC skills to program goals. 



2. Decisionmaking (DM) 



Use STEPS decisionmaking process. 2 
Set goals for improvement (desirable, 
realistic, specific, and measurable). 
Celebrate accomplishments. 
Apply DM steps to program goals. 



4. Interpersonal Communication (IPC) 



Express care and concern for others. 
Listen carefully and give feedback. 
Share thoughts and feelings tactfully. 
Give and receive constructive criticism. 
Apply IPC skills to program goals. 



FIGURE 1 . Key concepts of the PGC personal and social life skills 

2 STEPS: Stop, Think, Evaluate, Perform, Self-Praise 

SOURCE: Adapted and reprinted with permission from Eggert, L.L.; Nicholas, L.J.; and Owen, L.M. Reconnecting Youth: A 
Peer Group Approach to Building Life Skills. Copyright 1995 National Educational Service (Bloomington, IN). 



62 National Conference on Drug Abuse Prevention Research 



experiences a strong sense of belonging, and has 
a good experience in the group. Each student can 
develop trust in this culture, become motivated 
to change, internalize the program goals and key 
concepts, acquire and practice key life skills, and 
apply these skills in other classes at school and 
in life situations at home and at work. 

Group work in PGC follows a predictable se- 
quence of stages — from early, to middle, to late 
(see figure 2). Accompanying these stages also 
are predictable phases through which the group 
progresses, such as the following: 

• Forming and storming in the early stage of 
PGC — Ground rules are negotiated and es- 
tablished by the group and then tested as the 
students become more comfortable. 

• Norming and working in the middle stage — 
The students develop a common sense of pur- 
pose after "storming" and evidence the group 
norms and adopted behavior changes. 

• Working and ending in the late stage — The 
group reaches "maturity" during this stage, 
working on applying behavioral changes and 
preparing for life without the PGC group. 

The Life Skills Training Submodel 

While the group work submodel provides the 
critical foundation and "glue" for making PGC 
work, key behavior changes would be unlikely 



without the personal and social life skills train- 
ing. The life skills training provides PGC stu- 
dents with the building blocks they need to 
achieve the program goals. It also provides new 
ways of thinking, feeling, and behaving and cre- 
ates opportunities to apply these new skills to 
their current problems, concerns, strengths, and 
successes. 

In life skills training, leaders motivate, coach, 
reward, and reinforce. The leader's challenge is 
to make the training relevant and fun, for these 
are high-risk youth who reject traditional modes 
of learning. The leader also invites and encour- 
ages students to get back on track when they 
"slip." The goal is to prevent relapse into self- 
destructive or group-destructive behaviors. An- 
other leader task is to help students carry the skills 
they learn in PGC into other classes, friendships, 
family, and work relationships. 

Life skills training in PGC follows a sequence 
of motivating the student to become involved, 
then ensuring that the student is competent in a 
particular skill before expecting him or her to 
apply it to real-life situations. The four sequen- 
tial stages are 

• Motivational reparation 

• Skills-building 

• Skills practice and application 

• Skills transfer. 



Group 








Stages 


-^ r~-ii-lw hi ^ r/lirlrlln ^ -^ ' - i - *- 


^ Lai iy w ^ iviiQQie 


^ -^ Ldie ^ 


Group 








Phases 


Forming 


Storming Norming 


Working Ending 


Group 








Purpose, 
Objectives 


Ground 
Rules Set 


Testing Common Sense 

Rules of Purpose Adopted Behavior Changes 










Skills 

Training 

Stages 


Motivation, 
Assessment, 
Goals Set 


Skills-Building 
Skills 1,2, and 3 


Skills Practice and Boosters; 
Application to Skills Transfer 
Program Goals Reinforcers 



FIGURE 2. Linking group development and skills training stages 

SOURCE: Adapted and reprinted with permission from Eggert, L.L.; Nicholas, L.J.; and Owen, L.M. Reconnecting Youth: A 
Peer Group Approach to Building Life Skills. Copyright 1995 National Educational Service (Bloomington, IN). 



Reconnecting Youth 63 



The mode is to learn it, practice it, apply it, re- 
port back in the group on how it worked, and 
then get support, positive reinforcement, and 
praise. 

Integrating the Group Work 
and Skills Training Submodels 

Teaching PGC is both art and science. The art is 
in the process of integrating the skills training 
and group counseling submodels. The science is 
in the framework, content, and sequencing of the 
group stages and skills training. 

Integrating skills training within a PGC group is 
unique because only the objectives and key con- 
cepts of each lesson are standardized. The ex- 
amples and situations used for skills-building and 
application must come from the individual 
student's experiences and be developmentally 
appropriate for adolescents and multicultural 
groups. 

PGC group work, life skills training, and moni- 
toring are combined to achieve the following 
specific purposes: 

• Group support and caring to enhance a feel- 
ing of acceptance and belonging 

• Life skills training to enhance personal and 
social protective factors 

• Monitoring to help youth gain awareness of 
their need for behavior change and chart their 
progress toward success. 

After developing a supportive group environment 
and acquiring basic life skills, the students prac- 
tice these life skills by addressing their real-life 
problems. Boosters, or activities that reinforce 
understanding, use, and competency of the new 
skills, are promoted both within and beyond the 
PGC group. Cross-cultural understanding and 
acceptance are prominently featured and pro- 
moted. By using the students' real-life problems, 
beliefs, and values, PGC promotes cultural sen- 
sitivity in multicultural groups. Table 1 provides 
the organization and examples of group skills 
training units. 

The Daily PGC Experience 

A daily agenda helps to integrate group work and 
skills training. At the beginning of the class, the 



teacher starts with a "check-in" to monitor and 
assess each student, then leads into "bring 'n' 
brag," during which students are encouraged to 
report on successes. This is where the norm of 
support — praising steps taken toward minigoals 
and program goal achievement — is exercised. 
The teacher asks if anyone wants group support 
and problemsolving time for a personal issue, 
which leads into a preview of the training focus 
for the day. Once the leader has an idea of the 
students' issues, he or she finesses the relation- 
ship between issues and the skills-building and 
application objectives for the day. The students 
help set the agenda and take turns posting it on a 
flipchart, which helps focus the group work and 
group time. 

The Anti-Drug-Use Message 

In PGC, students share their feelings about many 
personal problems, including drug use and no 
drug use. Two key concepts are that problems 
are an opportunity for growth and that students 
can improve with the help of their friends. Many 
students already understand that their personal 
and school problems are linked with drug in- 
volvement. The PGC teacher helps the students 
assess their current drug involvement and set 
goals to reduce levels of drug use incrementally 
toward no use. 

The PGC approach assists youth to become and 
be drug-free. The teacher stops "war stories," so 
drug use is never positively reinforced. At the 
same time, the teacher supports a leadership role 
for those students who do not use drugs and 
enlists their help in sharing the reasons for not 
using and strategies for remaining drug-free. The 
leader provides praise and positive reinforcement 
for these behaviors and consistently counteracts 
any drug use "contagion effect" that occurs 
within the group. Not using drugs is rewarded as 
a healthy decision and a worthy model during 
check-in and during bring 'n' brag sessions. 

The PGC component is only one of four impor- 
tant elements in the Reconnecting Youth indi- 
cated prevention program. PGC as a stand-alone 
program is unlikely to be sustained. The PGC 
teacher and youth need a supporting cast to help 
reconnect at-risk youth to school, home, and 
community. 



64 National Conference on Drug Abuse Prevention Research 



TABLE 1 . Organization and examples of group skills training sessions 

PGC Social and Life Skills Training Units 







1. Self-Esteem 


2. Decisionmaking 


3. Personal Contro 


4. Interpersonal 


Unit Features 








Communication 


1 


Background: 












Key Concepts 


Positive self- 


DM is a process 


Personal control 


Verbal and 






esteem means 


of selecting from 


means coping 


nonverbal 






knowing and 


two or more possible successfully with 


exchanges that 






appreciating 


options to solve 


stress and feelings 


define relationships 






yourself. 


a problem or 


of depression, 


(e.g., expressing 








set a goal. 


anger, etc. 


care and concern, 
negotiating). 




Objectives 


Give accurate self- 


Make group 


Practice relaxation 


Practice refusal 






appraisal; practice 


contracts; set 


and exercise 


skills to resist 






positive self-talk, 


rewards for effective 


techniques. 


peer pressure. 






group praise. 


decisionmaking. 








Strategies 


Problemsolving 


Decisionmaking 


Adaptive coping 


Communicating 
support 


2 


Focus 


PGC's Best Self, 


Evaluating 


Stress Awareness: 


Communicating 




Sessions 


Support with Hugs, 


Decisions 


Stress Triggers, 


Acceptance of 






not Slugs 




Stressful Reactions 


Self and Others 


3 


Skill 1 


Positive Self -Talk: 


STEPS to 


Using STEPS 


Sending and 






An Affirmation 


Decisionmaking 


To Control Stress 


Receiving Clear 






A Day 






Messages: A Model 


4. 


Skill 2 


Positive Self-images: 


Mini-Decisions/ 


Getting Support 


Helping Friends: 






Visualizing Group 


Goals 


To Control Stress 


Taking STEPS, 






Strengths 






Helping vs. Enabling 


5. 


Skill 3 


Interrupting 


Time 


Working Out Stress 


The Give and Take 






Automatic 


Management 


Through Exercise 


of Conflict 






Thoughts 




and Fun Activities 


Negotiation 


6. 


Application: 


Removing 


STEPS to 


Getting Support 


Negotiating With 




Achievement 


Barriers 


Improved School 


To Improve School 


Teachers 






to Success 


Achievement 


Achievement 




7. 


Application: 


Dependency 


STEPS to 


Controlling 


Saying "NO" 




Drug-Use 


and Stress 


Drug-Use Control 


Addictive 


With Style! 




Control 






Behaviors 




8. 


Application: 


Emotional Spirals 


STEPS to 


Controlling 


Strengthening 




Mood 




Improved Mood 


Anger: Triggers 


Friendships and 




Management 






and Reactions 


Improving Mood 


9. 


Boosters for 


Self-Esteem 


The Refrigerator 


Your Piece of 


Rescue Triangle, 




Achievement: 


Enhancement 


Door Company, 


the Pie, 


Breaking the Ice, 




Drug-Use 


Boosters 


What Can 1 Say? 


Risky People/ 


Role-plays 




Control 




Recognition of 


Risky Places, 






Mood Control 




Improvement 


Anger Check-In 





SOURCE: Adapted and reprinted with permission from Eggert, L.L.; Nicholas, L.J.; and Owen, L.M. Reconnecting Youth: A Peer Group 
Approach to Building Life Skills. Copyright 1995 National Educational Service (Bloomington, IN). 



Reconnecting Youth 65 



Implementation Issues 

Anyone considering use of Reconnecting Youth 
will want to look at several essential issues and 
procedures before implementing the program. 

Administrative Leadership 
and Planning 

Launching Reconnecting Youth requires effec- 
tive administrative leadership, community sup- 
port, and talented group leaders/teachers. 
Program success requires the support of all part- 
ners. School personnel, parents, and community 
members all have important roles to perform, and 
all need to be involved from the start to coordi- 
nate the activities of Reconnecting Youth. Strong, 
committed administrative leadership is the "mas- 
ter key" for accomplishing the following tasks: 

• Develop a partnership model — Initiate a se- 
ries of meetings with important stakeholders. 
These individuals need to understand Recon- 
necting Youth — what it is, for whom it is de- 
signed, why it is needed, what evidence there 
is for its effectiveness, and how it might be 
paid for. Follow an agreement to proceed with 
planning meetings to establish in detail all 
aspects of an implementation plan. 

• Establish a community support team — Cre- 
ate linkages with community groups to form 
and strengthen the overall community sup- 
port for Reconnecting Youth and enhance the 
quality of program implementation. The key 
is to determine ways that willing community 
members can become constructively involved 
as partners in the school's efforts to imple- 
ment each component of the program. 

• Set up a school-based crisis response plan — 
Work out a crisis intervention plan to con- 
nect PGC youth with appropriate resources 
if needed. 

Preparation for Implementing 
the Personal Growth Class 

Having accomplished the "readiness tasks" listed 
above, the school administrator turns the focus 
to teaching PGC. 



Scheduling the Class 

PGC has to be part of the regular school curricu- 
lum, either as an elective or to meet certain re- 
quired credits such as psychology or health. 

Identifying and Selecting 
the Intended Participants 

Use the identification and selection model 
(Herring 1990), working from the school or 
school district's computer database. Alternately, 
select 9th- to 12th-grade students at random from 
the identified pool. This ensures a heterogeneous 
group across age, gender, ethnicity, maturity 
level, and the three presenting problems of school 
failure, drug involvement, and depression. Avoid 
existing cliques of deviant youth, which offer 
powerful pressure for them to continue to act out, 
be resistant, and negatively influence the other 
youth in the group. 

Inviting the Students To Join PGC 

Students from the eligible pool should be indi- 
vidually invited by the PGC group leader/teacher. 
The invitation must be motivational and appeal- 
ing while simultaneously communicating the 
purpose of PGC. 

The PGC Group Leader/Teacher 

The key to the success of the program is the 
leader/teacher. Leaders provide the most impor- 
tant human resource influencing the success of 
PGC. The group leaders observe firsthand the 
signs of underlying drug abuse or suicide risk in 
PGC youth. Without a competent, motivated 
group leader who has a history of being able to 
connect with these students, the program will not 
succeed. 

Identifying an Appropriate 
PGC Group Leader/Teacher 

Successful PGC leader candidates have experi- 
ence working with high-risk youth. Motivated 
leaders also are enthusiastic about the program 
and its goals and want to make a difference 
in the lives of these youth. Regardless of the 
discipline of the candidates, the common 



66 National Conference on Drug Abuse Prevention Research 



characteristic is the candidate's capacity for con- 
sistent and long-term caring for high-risk stu- 
dents. 

Selection Criteria 

Key criteria for selecting PGC leaders/teachers 
include the following: 

• Skilled in establishing helpful relationships 
with high-risk youth 

• Nominated by professional peers and by high- 
risk students as being effective 

• Motivated to teach PGC and work with high- 
risk youth 

• Stable with high self-esteem so they can put 
the needs of the youth first and consistently 
implement the key concepts of PGC as a 
healthy role model 

• Willing to regularly participate in teacher 
training and ongoing peer consultation 
groups, having the attitude that there is al- 
ways more to learn in being an effective group 
leader/teacher 

• Highly regarded by their faculty colleagues 
and an "insider" in the high school, therefore 
having greater opportunities for promoting 
school bonding 

• Committed to implementing the program 
(Eggert, Nicholas, and Owen 1995; Eggert, 
Thompson, et al. 1995; Eggert et al., Prevent- 
ing adolescent, 1994). 

PGC Group Leader 
Training and Support 

PGC group leader training is essential to the suc- 
cess of the program. The program is unlikely to 
achieve the expected outcomes unless it is imple- 
mented as designed. Two of the primary reasons 
why programs fall short of expectations are 
(1) the program is changed without consideration 
of how these changes alter the basic philosophy 
and interventions known to contribute to its 
original success, and (2) the program is only par- 
tially or selectively implemented, which alters 
the "dose" of what is delivered. 

Initial PGC Leader/Teacher Training 

Initial training typically consists of a 5-day work- 
shop covering the program philosophy, design, 



and rationale for the central goals of Reconnect- 
ing Youth. Also included is training in small- 
group discussion methods, skills-training 
strategies, and specific drug use and depression/ 
suicide prevention strategies. Detailed plans for 
the PGC sessions and implementation guidelines 
are studied and practiced extensively by means 
of videotape analysis and feedback. 

Ongoing Leader/Teacher 
Support and Consultation 

During the implementation of PGC, leaders need 
an ongoing source of support, encouragement, 
and consultation. A program coordinator from 
within the district can create a peer consultation 
and support group for the PGC leaders within a 
school district. When this type of ongoing sup- 
port and training was provided twice monthly in 
tests of PGC, all original teachers were sustained 
for the 5 -year duration of the program evalua- 
tion research. In addition, prevention of PGC 
group leader burnout was successful, and only 
two PGC leaders required replacement on the 
basis of factors unrelated to performance or in- 
terest. The teachers benefited from viewing each 
others' videotapes, comparing notes and experi- 
ences, and providing each other with exceptional 
peer supervision and consultation. 

Special Administrator and PGC Leader 
Working Relationship and Support 

To enhance success, the group leader must have 
the support of school principals. They must sup- 
port, in theory and practice, the need for the class 
and the unique nature of the curriculum. It is es- 
pecially important to work out ahead of time is- 
sues related to (1) confidentiality, (2) discipline, 

(3) serious depression and suicidal behaviors, 

(4) support from the counselors and other teach- 
ers in the school, and (5) collaboration with com- 
munity agencies and services. Policies related to 
all these issues must be consistent with the over- 
all philosophy and prevention goals of PGC. 

The teacher who conducts PGC as only one of 
his or her other regular daily classes cannot be 
expected to provide all the support needed for 
the high-risk youth involved. A coordinated team 
effort is essential to support these high-risk youth 
in schools. The school administrator should as- 
sume a key role in developing and maintaining 



Reconnecting Youth 67 



the necessary collaborative teamwork that is es- 
sential to the success of Reconnecting Youth. 

PGC Group Leader/Teacher 
Preparation: Ready, Get Set, Go! 

The successful PGC group leader is most often 
a school teacher who believes in the high-risk 
student for whom the program is intended and 
believes in the philosophy, integrity, and frame- 
work of Reconnecting Youth. This teacher is 
committed to these youth and to implementing 
the program as designed. Thus, in preparing to 
implement the program, the selected teacher 
needs to do the following: 

• Get ready to conduct the class by thoroughly 
understanding the "big picture," the basic 
framework and psychoeducational approach, 
and the structure and design 

• Understand the specific details and sequenc- 
ing of the lessons 

• Study and practice implementing the first 
10 days, which are a microcosm of the whole 
curriculum 

• Know how to assess his or her leadership ef- 
fectiveness so that when in doubt about the 
teacher's responsibilities and appropriate ac- 
tions, he or she can be guided by the under- 
lying principles of the PGC model 

• Know how to monitor the students' progress 
and use this feedback to help students, by us- 
ing both the PGC process evaluation and out- 
come evaluation tools provided to measure 
progress toward program goal achievement. 

This brief discussion of issues to consider be- 
fore implementing Reconnecting Youth illus- 
trates that there is more to "getting started" than 
assigning a teacher to be the group leader for a 
class called Personal Growth. Careful planning, 
preparation, and teacher training are essential. A 
coordinated effort among the students, parents, 
school personnel, and community members is 
critical. 

Evidence Gained From 
Reconnecting Youth 

Various aspects of the Reconnecting Youth pre- 
vention program were developed, implemented, 



and evaluated in stages in collaboration with 
Pacific Northwest high schools over the past 
12 years. Since 1985 the primary purpose has 
been to experimentally test school-based preven- 
tion efforts. This involved not only experiments 
with Reconnecting Youth as an indicated preven- 
tion program but also measurement studies and 
descriptive studies of high-risk youth and typi- 
cal high school students. Some of the more im- 
portant findings that are listed below demonstrate 
that high-risk students benefited and that their 
PGC leaders/teachers made a difference. 

• For students, not only has Reconnecting Youth 
had an effect on reducing drug involvement, 
it also has reduced other co-occurring prob- 
lems, such as poor school performance, ag- 
gression, depression, and suicidal behaviors 
(Eggert et al. 1990; Eggert, Thompson, et al. 
1995; Eggert et al., Preventing adolescent, 
1994). 

• Students who participated in the program 
showed sharp increases in personal control 
and school bonding; young women especially 
showed reductions in deviant peer bonding 
(Eggert, Thompson, et al. 1995; Eggert et al., 
Preventing adolescent, 1994). 

• The PGC teacher's expressed support and 
caring for the high-risk youth seemed to have 
the greatest influence on the positive out- 
comes for the program participants. It influ- 
enced decreased drug involvement (Eggert 
and Herting 1991), greater school achieve- 
ment (Eggert et al., A prevention, 1994), and 
decreased depression and suicidal behaviors 
(Thompson et al., n.d.). 

During the course of these experiments, Recon- 
necting Youth was refined in response to what 
was being learned. Stronger effects for reducing 
hard drug use and emotional distress occurred in 
the later years of program implementation. The 
current refined program (Eggert, Nicholas, and 
Owen 1995), which includes more anger man- 
agement (Eggert 1994b), depression manage- 
ment, and monitoring activities, works better than 
earlier versions (Thompson et al. 1997). 

Findings suggest that the program provided 
the typical participant with a positive experience 



68 National Conference on Drug Abuse Prevention Research 



in which the desired changes in school perfor- 
mance, drug use control, and emotional well- 
being occurred. 

Much also was learned from experiences with 
high-risk youth, specifically from studies that 
sought to explain more about the underlying 
causes of their poor school experiences and drug 
involvement. Some important findings and their 
implications include the following: 

• The effects on decreased drug involvement 
were primarily related to reductions in hard 
drug use (including use of crack, cocaine, am- 
phetamines). These were associated with de- 
creases in adverse drug use consequences and 
increased drug use control. Findings suggest 
that a second semester of Reconnecting Youth 
would be beneficial for obtaining stronger 
effects in reducing drug involvement and pre- 
venting relapse. This program refinement is 
currently being tested with support from 
NIDA (Eggert 1996a). 

• A major factor that impeded progress for Re- 
connecting Youth participants in reducing 
their drug involvement was family strain 
(Randell et al., in press). These findings sug- 
gest that having a stronger parent involvement 
component might also result in greater de- 
creases in drug involvement for the students. 
An initial demonstration project to test the 
feasibility of this approach is in progress and 
is supported by NIDA (Eggert 1996a). 

• Youth who received an indepth assessment 
of their risk and protective factors related to 
suicidal behaviors benefitted from this assess- 
ment protocol. They demonstrated sharp de- 
creases in depressed mood, suicidal behaviors, 
aggression, stress, and hopelessness. As a re- 
sult, this protocol has been expanded into two 
brief interventions. How these work to help 
potential high school dropouts who are also 
at risk of suicide is currently being tested with 
support from the National Institute of Nurs- 
ing Research and the National Institute of 
Mental Health (Eggert 1995). 

Before the studies noted above were conducted, 
it was necessary to develop some measurement 
tools. Two instruments in particular have proven 



reliable for assessing change over time in ado- 
lescents' levels of drug involvement and emo- 
tional distress: (1) the DISA, Drug Involvement 
Scale for Adolescents (Eggert et al. 1996; Herring 
et al. 1996), and (2) the MAPS, a computer- 
assisted Measure of Adolescent Potential for Sui- 
cide (Eggert 1994a; Eggert et al., A Measure, 
1994). These instruments are unique. The DISA 
not only measures the frequency of alcohol use 
and other drugs used but also taps the levels of 
access to drugs, drug-use control, and adverse 
drug use consequences. This is important because 
researchers can analyze the effects of the vari- 
ous program components in Reconnecting Youth 
on these separate dimensions of adolescent drug 
involvement. This ability will help in discover- 
ing more about how to best help high-risk youth 
achieve the goal of becoming drug-free. 

Similarly, the MAPS is unique in that it provides 
a comprehensive assessment of the risk and pro- 
tective factors associated with not only suicide 
potential but also adolescent drug involvement 
and potential for dropping out of school. Because 
it is a computer-assisted interview, it provides 
the interviewer with an instant profile of the stu- 
dent interviewed. When current refinements and 
tests are complete, this instrument should pro- 
vide the kind of data required for implementing 
indicated prevention programs for high-risk 
youth. 

In developing Reconnecting Youth, the research- 
ers also developed a full set of tools useful for 
process evaluation. With these tools, provided 
in the leader's guide (Eggert, Nicholas, and Owen 
1995), those implementing the program are able 
to assess whether the program is being imple- 
mented as designed and how the students respond 
to their program experience. 

Conclusion 

The Reconnecting Youth program is one model 
of how prevention science is advancing. The 
promised benefits of indicated prevention pro- 
grams for stemming adolescent drug involvement 
and related problem behaviors far outweigh the 
emotional and economic costs of doing nothing. 
The costs of prevention are also far less than those 



Reconnecting Youth 69 



of treatment, once drug involvement and depres- 
sion are diagnosed as disorders. 

Adolescence may represent the last best chance 
for high-risk youth to change their life course. 
To do this, they need our best efforts in preven- 
tion programming. Schools are ideal for indicated 
prevention programs for high-risk youth. School 
is central to the way in which these youth are 
socialized, and school is a place where they use 
and share drugs. By addressing the challenges 
of these youth and providing a better school ex- 
perience that fosters a sense of belonging and 
purpose, key risk and protective factors in their 
lives are altered. School performance improves, 
drug involvement decreases, and the emotional 
distress expressed in depression, aggression, and 
suicidal behaviors declines. This experience 
should stimulate others to join in supporting in- 
dicated prevention programs for potential high 
school dropouts, as well as for other high-risk 
individuals. 

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Vorrath, H. and Brendtro, L. Positive Peer Cul- 
ture. 2d ed. Chicago: Aldine, 1985. 



72 National Conference on Drug Abuse Prevention Research 



Preventing Drug Abuse Through 
the Community: Multicomponent 
Programs Make the Difference 

Mary Ann Pentz, Ph.D. 

Associate Professor, Department of Preventive Medicine 

Director 

Center for Prevention Policy Research 

University of Southern California 



Introduction 

Since 1991, after a relative hiatus of several 
years, drug use, including tobacco and marijuana 
use, among U.S. adolescents has been on the in- 
crease, and more recently, illicit drug use as a 
whole (Johnston et al. 1995). The question is, 
why? 

One major hypothesis is that after a decade of 
intense public attention to the youth drug use 
problem, the U.S. public may have experienced 
burnout (Johnston 1996, pp. 17-18; Bachman et 
al. 1990). The intense focus of attention has been 
indicated by national mass media coverage, spe- 
cial attention to drug abuse education in schools, 
and an influx of Federal dollars for prevention 
research and demonstration projects. The burn- 
out manifests itself as the antithesis of indica- 
tors of public attention: low mass media 
coverage, poorer implementation of and lower 
budgets for drug education in schools, and loss 
of Federal dollars for prevention education re- 
search. These funds have been appropriated else- 
where to novel areas of public interest, such as 
violence, and underserved populations, and mi- 
nority and rural populations of youth. 

Decreased attention to universal drug abuse pre- 
vention, that is, specific drug abuse prevention 
and education for all youth, may increase drug 
use by sending an inadvertent message to youth 
that drugs are either more tolerated or less preva- 
lent (perceived social norm) or not as harmful as 
previously thought (perceived personal risk, 
Bachman et al. 1990). Sustained reversal of the 
attentional problem and related drug use media- 
tors may depend on a community -based approach 



to drug abuse prevention. This would necessi- 
tate a comprehensive programmatic and policy 
intervention strategy integrating multiple, varied 
community intervention channels that together 
and over time are most likely to reinforce youth 
prevention practices and promote non-use social 
norms in the community. 

Several questions arise in consideration of a com- 
munity approach to drug abuse prevention com- 
pared with single or smaller channel approaches 
such as school or parent programs. First, on a 
general level, should a community adapt or tai- 
lor a strategy based on previous research and 
theory or develop a new strategy? The former 
decision assumes a consistent set of behavior 
change principles and results that can generalize 
across communities; the latter assumes that each 
individual community is unique and that a 
community's leaders should fashion a prevention 
program based solely on their own perceived 
needs and preferences. 

A second general question is whether commu- 
nity leaders should organize and develop a pre- 
vention program according to a formal, agreed-on 
process, meet briefly to catalyze others' efforts 
to promote drug prevention, or meet initially and 
let the chips fall where they may. The first deci- 
sion would be based on research, the second on 
an assumption of community reactivity, and the 
third on no assumption. 

Finally, in general, should a community develop 
a structure according to which certain identified 
parties are held responsible for program planning, 
training, implementation, and evaluation, or 



Multicomponent Programs Make the Difference 73 



should these activities be dependent on the avail- 
ability and interest of volunteers? Again, the first 
decision is based on research, the second on ex- 
isting resources. 

In addition to general questions that will define 
a community's overall approach to drug abuse 
prevention, several specific questions arise. 
These questions are most likely to be raised by 
the parties in the community who perceive them- 
selves as decisionmakers for a prevention pro- 
gram. First, what components or ingredients of 
a community program can produce a significant 
change in drug use behavior? Second, how large 
is a significant effect, and will this effect be in- 
terpreted as meaningful by the community? 
Third, is continuous programming across differ- 
ent ages and grade levels required to sustain a 
long-term program effect? The community can 
address all of these specific programmatic ques- 
tions by referring to previous research. Where 
research is lacking, comprehensive theories of 
behavior change can guide a community's deci- 
sion to adopt a particular prevention program or 
strategy. 

Review of Theory 

Person-level (P) theories of behavior change sug- 
gest that programs aimed at changing personal 
attitudes about, and the value and consequences 
of, drug use are more likely to change individual 
drug use behavior than are those aimed at chang- 
ing knowledge or at providing information about 
drugs (Ajzen and Fishbein 1990). Added to this 
are theories of cognitive problemsolving and in- 
tentions, which suggest that skills training and 
public commitments against drug use can change 
an individual's decision and intentions to use 
drugs (Petraitis, Flay, and Miller 1995). 

Situation-level (S) theories of behavior change 
are those that focus on changing interpersonal 
and group behavior. The most effective among 
these for changing drug use behavior by youth 
are the social influence theories, including so- 
cial learning theory, self-efficacy theory, and 
social normative expectancy value theory 
(Bandura 1977; Rotter 1954). These theories 
suggest that drug use behavior can be prevented 
or changed by teaching youth how to avoid or 
counteract social pressures, such as group peer 



pressure, to use drugs and how to correct per- 
ceived social norms for drug use. These theories 
further suggest that interactive program imple- 
mentation methods are more likely to change 
behavior than didactic methods. 

Environment-level (E) theories suggest that 
changing the community norms for drug use, 
enabling diffusion of prevention programs and 
messages, and empowering community leaders 
to take responsibility for drug use prevention are 
the means by which prevention programs are 
likely to effect changes in drug use behavior, 
particularly over the long term. These theories 
include diffusion of innovation, organizational 
change, mass communication, and empowerment 
theories (Rogers and Storey 1987, pp. 817-846; 
Pentz 1986; Goodman et al. 1996). 

All three levels of these theories should be inte- 
grated in the conceptualizing, design, implemen- 
tation, and evaluation of community drug abuse 
prevention programs. P-level theories explain 
how the norms, attitudes, and behaviors of indi- 
viduals can be changed. Programs based on these 
theories, if implemented with successively larger 
groups and populations, are likely to change per- 
ceived group norms and actual community norms 
as well, according to S- and E-level theories. 
Programs incorporating S-level theories build 
peer and family support for prevention practices. 
Incorporating E-level theories extends drug use 
prevention messages, norms, support, and re- 
sources to the community. E-level theories also 
improve the likelihood that programs will be 
maintained or institutionalized over the long 
term. 

A community-based drug abuse prevention pro- 
gram based on an integrated P X S X E theoreti- 
cal model would most likely include the use of 
multiple program channels that represent P, S, 
or E levels of influence on youth, including 
school, family or parents, community organiza- 
tion, mass media, and policy (Pentz 1986; Pentz 
1994a). According to an integrated theoretical 
model, use of these program channels would be 
staged or sequenced into the community to maxi- 
mize initial learning, boost learning effects, dif- 
fuse prevention support, and maintain public 
interest. 



74 National Conference on Drug Abuse Prevention Research 



In addition to a theoretical model of behavior 
change, the complexity of mounting a 
communitywide drug abuse prevention effort 
requires attention to theories pertaining to orga- 
nizational process (that is, the process by which 
a community can adopt, implement, and main- 
tain a program) and structure (that is, the struc- 
ture developed to promote and take responsibility 
for this process). Organizational theories relevant 
to community prevention programming suggest 
that a process with identifiable time-limited steps 
or objectives to be completed empowers com- 
munity leaders to implement a program effi- 
ciently; such a process should include conjoint 
feedback and evaluation at each step before the 
next step is addressed (Goodman et al. 1996; 
Pentz 1986). Relevant structural theories suggest 
that community leaders form a council or coali- 
tion with several committees organized by re- 
sponsibility for specific drug use risk factors such 
as drug accessibility, or by program channels 
such as mass media (Boruch and Shadish 1983; 
Pentz et al. 1989). 

Review of Research 

The development of a community drug abuse 
prevention program should be guided by previ- 
ous research as well as by theory. Research in- 
corporating one or more program channels 
relevant to community-based youth drug abuse 
prevention were reviewed. The review was re- 
stricted to published studies appearing in 
PsycINFO and MEDLINE searches, and in three 
cases, studies whose recent results are under re- 
view for publication. A total of 20 prevention 
studies and 4 reviews representing 96 commu- 
nity demonstrations resulted. Studies are sum- 
marized by type (tobacco, alcohol, other drug, 
heart disease or cancer with smoking compo- 
nent), evidence of use of theory (yes or no), re- 
search-based programs (yes or no), evaluation 
of process (yes or no), formal community struc- 
ture organization (yes or no), and program com- 
ponents (mass media, school, family, community 
organization, policy change). Results are shown 
in table 1 . 

Of the 24 studies and reviews, 10 (42 percent) 
relied on a theoretical model of behavior change; 
16 (67 percent) relied on previous research to 
guide program development. Five (21 percent) 



used a process model to guide development of a 
coalition or program planning, and 62 percent 
used a structure or structural model to develop 
planning responsibility. Overall, reliance on pre- 
vious research was associated with more changes 
in drug use behavior than reliance on theory, pro- 
cess, or structure, although most research-based 
studies also included theory, process, and struc- 
ture. 

Based on youth-related experiences of the heart 
health trials, multicomponent community-based 
programs should include substantial school pro- 
gramming to initiate behavior change in conjunc- 
tion with a community organization structure and 
process that promotes mass media programming 
and coverage, parent and adult education, and 
informal or formal policy change (Mittelmark et 
al. 1993). A standard for comparison might be 
the 2- to 15 -percent short-term decreases found 
in school-based studies of smoking prevention 
(Pentz 1995). 

Among studies with a community component 
alone, the two studies involving Boys and Girls 
Clubs educational programs and activities both 
showed significant short-term decreases in ciga- 
rette, alcohol, and marijuana use compared with 
short-term decreases reported for school-based 
programs (see Schinke et al. 1992; St. Pierre et 
al. 1992; Pentz 19946). Three studies of coali- 
tions showed that community or organization 
without education was ineffective overall in 
changing drug use behavior. 

Overall, results of programs that included one 
or more community program components with 
a school educational program showed short-term 
effects on monthly smoking and drug use simi- 
lar to those of comprehensive school programs 
that included a large number of sessions and 
boosters (see Botvin et al. 1995). However, the 
effects of school plus community programs ap- 
peared to have a greater range of effects and 
larger long-term effects on heavier use rates, 
averaging 8 percent net reductions (Pentz 1995). 
Community programs with a school component 
were the only programs to show any effects on 
parent behavior. 

Thirteen (54 percent) of the studies and reviews 
included some type of community organization 
or education with a school program. For example, 



Multicomponent Programs Make the Difference 75 



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Multicomponent Programs Make the Difference 77 



10 studies (42 percent) combined parent involve- 
ment through education or homework with a 
school program (Eggert et al. 1990; one review 
of four studies in Flay et al. 1985, 1995; Perry et 
al. 1992; Barthold et al. 1993; Shea et al. 1992; 
Stevens et al. 1993; Perry et al. 1993; Murray et 
al. 1994; Pentz 1993). Five of these suggested 
that parent involvement increased effects on 
youth health behavior; three studies suggested 
that parent involvement increased effects on par- 
ents. 

Thirteen studies (54 percent) included a mass 
media component. Three of these suggested that 
media changed parent behavior (Flay et al. 1985; 
Flynn et al. 1992; Pentz 1993). 

Several (29 percent) of the studies included some 
informal or formal policy change component 
(Perry et al. 1992; Barthold et al. 1993; Shea et 
al. 1992; Stevens et al. 1993; Perry et al. 1993; 
Hingson et al. 1996; Center for Substance Abuse 
Prevention 1996). Policy change mostly involved 
reducing youth access to substances and control- 
ling product availability. Effects of policy inde- 
pendent of other components could not be 
determined. 

Six studies (one a review) directly compared a 
school program component with parent and/or 
mass media components (Flay et al. 1995; Flynn 
et al. 1992; Kaufman et al. 1994; Murray et al. 
1994; Stevens et al. 1993). Overall, these stud- 
ies showed greater effects on youth drug use 
when community intervention included a school 
program and when school programs included par- 
ent and/or mass media programs. 

In 1984 a comprehensive community-based drug 
abuse prevention trial, the Midwestern Preven- 
tion Project (MPP), was initiated in Kansas City; 
in 1987 a replication was initiated in Indianapo- 
lis. In both cities, by design, the native program 
implementation period extended through 1991. 
Since 1991 approximately 25 percent of Kansas 
City schools have retained the school program 
component; over 80 percent of Indianapolis 
schools and communities have retained the 
school, parent, and community program compo- 
nents. In both cities, retention of programming 
after 1991 represents institutionalization of a 
theory- and research-based program by the com- 
munity with its own funds and resources. 



Method 
Subjects 

Adolescents entering middle school (sixth grade) 
or junior high school (seventh grade) in fall 1984 
in Kansas City and in fall 1987 in Indianapolis 
were the study population. From the transition 
cohort, approximately one-third of the popula- 
tion was randomly selected by classroom from 
each school and recruited for study participation 
with parental consent. More than 90 percent par- 
ticipated. The results summarized in this paper 
are based on two of multiple samples studied: a 
grade cohort sample that included a panel 
(N=5,400, N=50 schools, Kansas City), and a 
panel sample (N=3,192, N=57 schools, India- 
napolis). The study population was approxi- 
mately 70 percent white, 23 percent African 
American, and 7 percent other. 

Research and Measurement Designs 

Schools within each community (N=26) were 
assigned to an intervention or delayed interven- 
tion control condition, a two-group design. Be- 
cause the MPP in Kansas City started after the 
school year began, assignment of all but 8 of the 
50 schools was based on administrator ability to 
change schedules; the remaining 8 were ran- 
domly assigned. All 57 schools in Indianapolis 
were randomly assigned to the program or con- 
trol condition. The measurement design was lon- 
gitudinal, with students administered a survey 
and a comeasure at baseline and each year. 

Intervention Models 

Three models were used to develop the MPP: 
(1) the P (person) x S (situation) x E (environ- 
ment) transactional theoretical model, on which 
hypotheses, measures, program content, and 
implementation were based; (2) the 10-step or- 
ganizational process model, used to integrate re- 
search and local program planning, organize 
community leaders, and evaluate program plan- 
ning and implementation; and (3) a structural 
model, used to organize, sequence, and assign 
responsibility for a community needs assessment, 
community organization training program imple- 
mentation, and evaluation (Pentz, in press; Pentz 
1986; Pentz et al. 1989; Pentz 1993). These are 
shown respectively as figures 1, 2, and 3. 



78 National Conference on Drug Abuse Prevention Research 



Person 



Situation 



Prior drug use 






Peer influences 


Intentions to use 




Prior skills practice with peers 


Prior skills 
Prior appraisal 




Family influences 
Social support 




Prior social support seeking 




Transitions 


Physiological reaction 




Exposure to drugs 




I 

Environment 


1 




Media influences 






Availability ot prevention resources 






Prevailing community norms 






Demographic factors 






Fiscal resources 






School/community policy 








' 


r 








Incidence 






Prevalence 






Intensity 








Duration 







FIGURE 1 . The P x S x E transitional 
theoretical model 

SOURCE: Reprinted with permission. M.A. Pentz, CSAP 
NPERC Prevention Evaluation Report, in press. 

Intervention 

The MPP community-based intervention, re- 
ferred to locally as Project STAR or I-STAR, tar- 
geted avoidance and reduction of drug use, with 
special emphasis on prevention of cigarette, al- 
cohol, and marijuana use in middle/junior high 
school. Five program components were imple- 
mented: (1) mass media coverage, promotional 
videotapes, and commercials about each program 
component; (2) an 11- to 13-session school pro- 
gram with 6 homework sessions with parents 
followed by a 5-session booster school program 
with 3 homework sessions; (3) a parent organi- 
zation program involving parent-principal meet- 
ings and parent-child communications training; 
(4) a community organization program to orga- 
nize and train community leaders to develop ac- 
tion groups; and (5) drug use policy change. 
Content and implementation methods for all 
program components were derived from several 
theories, including social learning theory 
(Bandura 1977), training resistance skills through 
the use of modeling, rehearsal, feedback 
with Socratic discussion, reinforcement, and ex- 
tended practice; attribution and value expectancy 
theories (Azjen and Fishbein 1990), correcting 



perceptions of social consequences of drug use 
and social normative expectations about drug 
use; cognitive development theories, making 
public commitments to avoid drug use; prepar- 
ing for school and developmental transitions 
(Pentz 1994&); communication theories (Rogers 
1987) promoting positive parent-child and mass 
media communication; and social support. The 
order and phasing of program components, with 
one component introduced into communities at 
the rate of 6 months to 1 year apart, were based 
on diffusion of innovation and other mass com- 
munication theories (Rogers 1987). 

The mass media program component focused on 
disseminating information about other program 
components to the public at large, presenting 
brief prevention skills, and presenting messages 



Organization 



Evaluation 



Identify target 
population 



Conceptualize 
community unit 




Identify 
community leaders 



Conduct 
introductory 
workshops 



Meet to adopt 
program 




Establish 

coordinating 

structure 



Conduct program 
planning 



Train program 
implementers 



Implement program 
with target 
population 

9 



Reinforce 
implementers and 
target population 
10 




FIGURE 2. The 1 0-step organizational process 
model 

SOURCE: Reprinted with permission. M.A. Pentz, J Sch 
Health. Copyright 1986. 



Multicomponent Programs Make the Difference 79 



Assessment of community drug 

use problem and prevention 

needs and resources 



Community entry 
and preparation: 



Introductory training of 
community leaders in problem 
awareness and program need 



Establishment of 

community coordinating 

structure 



Training of program 
implementers 



School and local 

government 

administrators 




Program 
Focus: 



Indirect skills to support 
resistance practice 



Direct skills in 
resistance and 
counteraction 



Target 
behaviors: 



X 



Environmental support for 

changing social norm of 

drug use 



Reduction of 
drug use prevalence 



Reduction of 
drug use morbidity 



Promotion of 
non-drug-use 
social norms 



FIGURE 3. A structural model used to organize, sequence, and assign responsibility for 
program development 

SOURCE: Reprinted with permission. M.A. Pentz, et al. JAMA. Copyright 1989. 



targeted to youth and parents. The mass media 
component included an average of 3 1 television 
and print media segments each year beginning 
in the first year. 

The school program component focused on train- 
ing students how to recognize and counteract 
social influences to use drugs, including peer 
pressure, drug use modeling by parents and other 
adults, and glamorized portrayals of drug use in 
ads and mass media programs. The school pro- 
gram was implemented by trained teachers and 
student peer leaders in regular science or health 
education classes in 18 classroom sessions over 
the first 2 years. 



The parent program component focused on de- 
veloping a comprehensive school drug abuse 
prevention policy, deterring drug use on and near 
school grounds, and training parents in parent- 
child communication and prevention support 
skills through a series of organizational meet- 
ings and activities. The parent program was 
implemented by a core group of trained princi- 
pals, two to four parents, and two student peer 
leaders in each school who met throughout each 
school year in the second and third years. 

The community organization component focused 
~n identifying and training community leaders 
drug abuse epidemiology and prevention. The 



on 

in 



80 National Conference on Drug Abuse Prevention Research 



organization developed citywide campaigns for 
drug abuse prevention to complement and rein- 
force prevention messages delivered in the other 
program components, facilitated referral and in- 
formation networks among drug abuse preven- 
tion and treatment agencies, and supported and 
extended public education about the program to 
population groups not directly targeted by the 
other program components. Following the Min- 
nesota Heart Health Project and other similar 
community organization models (Mittelmark et 
al. 1993), community leaders were organized as 
a council with eight action committees designed 
to develop and implement prevention initiatives 
according to youth-serving function (legislative, 
worksite, health/medical, educational, religious, 
youth social service/recreational, parental, and 
treatment [Mansergh et al. 1996]). The action 
committees met every 4 to 6 weeks, beginning 
in the third year. 

Beginning in the fourth year, the policy compo- 
nent used the parent program committee from 
each school and the community organization to 
review and refine school drug-free zone policies, 
develop restricted use and access policies for 
youth at the community and city levels, develop 
mandates for funding youth prevention and treat- 
ment services, and lobby for a beer tax. 

Measurements 

A multiform questionnaire was administered in 
the classroom to all subjects by trained project 
data collectors who were independent of program 
implementation or training (average N of items 
= 116). Subjects were measured at baseline and 
at annual followups. 

The questionnaire assessed frequency and 
amount of tobacco, alcohol, and marijuana use 
and other illicit drug use; psychosocial variables 
related to drug use, including use by peers and 
parents; and demographic characteristics. Imme- 
diately preceding questionnaire administration at 
baseline and each followup, carbon monoxide 
(CO), a byproduct of cigarette and marijuana 
smoking, was measured with a MiniCo Indica- 
tor (Catalyst Research Corp., Owings Mills, 
MD). The CO measure was used as a "pipeline" 
to increase the accuracy of self-reports of drug 
use. 



Statistical Analysis 

Several alternative statistical models were used 
to estimate program effects, including conditional 
(covariance) and unconditional (change score or 
repeated measures) models; linear regression 
with school as the unit of analysis and logistic 
regression with the individual as the unit of analy- 
sis; ordinary least squares estimation and 
weighted least squares estimation adjusting 
for differences in individual school sample 
sizes. Findings were similar across the alterna- 
tive approaches. The results summarized here 
focus on ordinary least squares estimates, with 
school as the unit of analysis to match the unit of 
intervention. 

Results 

The general pattern of program effects through 
the end of high school is shown in figure 4, 
using unadjusted data on cigarette smoking in 
Kansas City as an example (Pentz 1993). Effects 
of the community-based program on cigarette, 
alcohol, and marijuana use have maintained be- 
yond the end of high school and into early adult- 
hood. Similar to comprehensive school programs 
involving many sessions and boosters, the MPP 
showed average decreases of 8 to 15 percent 
in cigarette and marijuana use, or a 20- to 
40-percent net program effect, for the 3 years 
associated with program participation by stu- 
dents. Beyond the 3-year mark, the MPP showed 
greater and more sustained effects on heavier use 
rates than those reported by school or other single 
channel programs, including an average reduc- 
tion of 4 percent in daily cigarette use, monthly 
drunkenness, and heavy marijuana use two or 
more times in the preceding week (Botvin et al. 
1995). 

Beyond the end of high school, effects have 
emerged on the use of some stimulant classes of 
drugs, including amphetamines and cocaine, but 
not on depressants. 

Discussion 

The following questions serve as directions for 
future research, answers to which could improve 
future community prevention practices. 



lulticomponent Programs Make the Difference 81 



20 - 



>. — 



Q 

(A 

i 

ra 
g> 

O 



a) 
o> 
ra 

c 
a> 

£ 



15 - 



10 - 



5 - 















- 




Program -■- 


Control + 














— 








+ 


— 


.+ ■••" 


,..-•+. 


'+' 


;•' 




JS >^ 








— 


• ^r 








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^^^~~ 








__ ■ 










" +' 










- 











Baseline 



Yearl 



Year 2 Year 3 

Followup 



Year 4 



Year 5 



FIGURE 4. Midwestern Prevention Program effects on unadjusted cross-sectional prevalence rates 
of daily cigarette use in Kansas City as an example 

SOURCE: Reprinted with permission. M.A. Pentz, CSAP NPERC Prevention Evaluation Report, in press. 



Is school plus community better than school or 
community alone? This paper suggests that, over- 
all, yes, it is. However, a more definitive answer 
depends on studies using research designs that 
directly compare these components. 

Are school-plus-community programs repli- 
cable? Given the consistency of positive find- 
ings of school-plus-community programs on 
youth and parent behavior, the general answer 
appears to be yes. However, communities show 
great variability in the structure and action plans 
of a coalition, council, core team, or task force 
component used to plan drug prevention. This 
type of component may not be replicable in a 
standardized fashion but could be evaluated as 
part of a qualitative or quantitative process and 
implementation analyses, as the Robert Wood 
Johnson and Center for Substance Abuse Pre- 
vention studies have attempted. 



Is school-plus-community research feasible with 
multiple communities? Several methodological 
papers have indirectly addressed this question 
(e.g., Boruch and Shadich 1983, pp. 73-98; 
Goodman et al. 1996; Manger et al. 1992; Pentz 
1994a; Koepselletal. 1992; Wiener etal. 1993). 
The demographics and past drug use behavior 
of communities are difficult to match, suggest- 
ing that a large number of communities would 
be necessary for randomizing to experimental 
conditions, with the community as unit. Such a 
study is expensive. Most of the studies reviewed 
here included multiple community components 
versus a control or delayed intervention control 
group. The ability to evaluate the effects of sepa- 
rate components in a community intervention 
would require the use of a factorial design, 
in which effect size associated with each com- 
ponent intervention or sets of components 



82 National Conference on Drug Abuse Prevention Research 



compared with each single component interven- 
tion would be assumed to be significantly dif- 
ferent. Only a few studies have had cell sizes 
large enough to detect differences between in- 
terventions or components of interventions (e.g., 
Flynn et al. 1992; Flay et al. 1995). 

Are school-plus-community programs cost-effec- 
tive? A recent analysis of the prototype-integrated 
school health education programs included pro- 
jected costs and reported outcomes from seven 
comprehensive school-based programs and two 
school-plus-community programs (Rothman 
1995). Results indicated that annual costs per 
student for program delivery ranged from $10 to 
$35. Effects, measured as percentage of net re- 
duction between program and control groups, 
ranged from 6 to 9 percent. The benefit-to-cost 
ratio was 19 for smoking. A recent analysis of a 
school-plus-community program for drug abuse 
prevention supports these findings (Pentz 1996, 
pp. 1-22). 

Over the long term, who should coordinate 
school-plus-community programs, and who 
would fund these programs? The research stud- 
ies reviewed here varied in terms of who was 
responsible for coordinating programming, in- 
cluding research staff members, health educa- 
tors, school personnel, and paid and volunteer 
community leaders. None of the studies system- 
atically compared the effectiveness of types of 
coordinators (see Goodman et al. 1996). A ma- 
jor question is whether coalitions that draw from 
community leaders but are organized by the 
school or school district generate more or less 
credibility and cooperation than coalitions that 
draw from community leaders and are organized 
by the community. The studies reviewed here 
showed the latter, but no comparisons with the 
former were made. If coalitions are used to co- 
ordinate school health education, then commu- 
nity agencies and Federal and State funds that 
are allocated to community agencies for health 
services might be used to augment existing 
school drug education budgets. However, if 
school-based health advisory councils are used, 
then accessing community health care funds may 
be difficult and resented. A long-term alterna- 
tive would be qualifying school health clinics and 
health education as a managed health care ser- 
vice delivery organization, reimbursable by in- 
surance and Federal funds (Pentz 1995). In this 



case, managed care funds could be combined 
with existing school health education funds to 
create a unified funding package for school health 
education. As long as health care reimbursements 
were forthcoming, this alternative should be more 
stable than relying on the graces of volunteered 
community agency funds. 

Can integrated school-plus-community programs 
affect educational outcomes as well as health 
outcomes? Comprehensive school programs that 
included more than seven sessions, booster ses- 
sions, standardized training, and monitoring of 
implementation, had substantial effects on 
knowledge change, as did school-plus-commu- 
nity programs; no substantial differences were 
apparent. To the extent that knowledge is meas- 
ured as an educational outcome in health educa- 
tion classes, comprehensive school programs and 
integrated school-plus-community programs 
could be considered effective in improving edu- 
cational achievement. However, no studies re- 
ported a health program having significant effects 
on grade point average, absenteeism, or dropout 
rates, which are considered key indicators of 
educational achievement. 

Summary 

A review of multiple studies suggests that a com- 
munity prevention program can vary in the use 
of mass media, parent programs, community 
education and organization, and local policy 
change. Results suggest that community-plus- 
school programs may yield greater effects on the 
more serious levels of drug use (e.g., on daily 
smoking compared with monthly smoking), 
effects on parents as well as youth, and perhaps 
more durable effects than are currently obtain- 
able from most school programs alone. Overall, 
the magnitude of effects on smoking and sub- 
stance use appears slightly greater for school- 
plus-community versus school programs alone 
(6- to 8-percent net reductions). 

The review of studies points to several gaps in 
the literature, which should serve as directions 
for future research. These include the following: 

• More systematic evaluation of the cost- 
benefit and cost-effectiveness of school and 
school-plus-community programs that rely on 
true costs 



Multicomponent Programs Make the Difference 83 



• Evaluation of the efficacy of extensive school 
programming alone (i.e., 30 sessions or more 
with boosters delivered over several years) 
versus the same school programming with ad- 
ditional community components, with school 
district/community as the unit of assignment 
and analysis if possible 

• Comparison of school-plus-community pro- 
grams that vary in intensity or type of com- 
munity involvement. 

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86 National Conference on Drug Abuse Prevention Research 



Advances in Family-Based Interventions 
To Prevent Adolescent Drug Abuse 



Thomas J. Dish ion, Ph.D. 
Research Scientist 
Oregon Social Learning Center, Inc. 
University of Oregon 



Introduction 

There is reason for concern that the number of 
children enjoying success and good health may 
be decreasing in many communities. The over- 
all rate of problem behavior in children 
(Achenbach and Howell 1993), rates of violence 
among children (Dishion et al. 1995, pp. 421- 
471), and the use of drugs in adolescence seem 
to be increasing, while the age of use is decreas- 
ing (Mathias 1996, pp. 8-9). 

Targeting young adolescent drug use is a critical 
ingredient for the prevention of substance abuse, 
as onset by age 15 to 16 is among the best pre- 
dictors of abuse in young adulthood (Robins and 
Przybeck 1985, pp. 178-193). To prevent early- 
onset drug use, it is necessary to organize inter- 
ventions around the promotion of attentive and 
positive parenting with young adolescents. This 
statement is justified by findings from two areas 
of research. First, studies on the development of 
adolescent drug use show that such risk trajecto- 
ries are directly or indirectly embedded within 
family disruption. Second, careful intervention 
research indicates that targeting families affects 
risk factors and adolescent problem behavior. The 
implementation of effective prevention practices 
depends on our collective understanding of the 
role of the family in the development of adoles- 
cent drug use and the effectiveness of family- 
based interventions. The following conclusions 
are based on extensive research conducted over 
the past 20 years: 

• Parenting practices are central to children's 
development of risk for drug abuse. 

• Family interventions are effective in reduc- 
ing risk among children and adolescents. 



• There are clear ingredients to those interven- 
tions that effectively target parenting prac- 
tices. 

• Family interventions can be integrated with 
other intervention strategies. 

• Family interventions are economically fea- 
sible. 

Central Role of Parenting 

There is no single definition of success with chil- 
dren and adolescents. Similarly, positive 
parenting may take on a variety of forms depend- 
ing on the culture, community context, and con- 
stellation of the family. Most parents are quite 
invested in their children's success and good 
health. As children mature, however, there is a 
natural tension that leads to increasing levels of 
independence and autonomy. Parenting in early 
and middle childhood sets the stage for the tran- 
sition into adolescence. Continued parental sup- 
port and positive family management can further 
reduce risk and promote success during this life 
juncture. 

The scientific community has focused exten- 
sively on the role of parenting in establishing, 
maintaining, or exacerbating risk trajectories in 
children and adolescents. The goal of this re- 
search is to improve the understanding of devel- 
opmental patterns leading to adolescent drug 
abuse as well as to identify which parenting prac- 
tices to target in intervention and prevention tri- 
als. We now know a great deal about the risk and 
protective factors associated with adolescent 
problem behavior (Hawkins et al. 1992; Pandina, 
this volume). Early-onset drug use does not 
appear randomly, but is often a predictable 



Advances in Family-Based Interventions 87 



and identifiable outcome of a developmental 
progression that begins early in childhood (see 
figure 1). 

Longitudinal studies that examine children be- 
fore they begin using drugs are relatively rare. 
However, from the available evidence, it is clear 
that aggressive or antisocial behavior in child- 
hood precedes substance use in adolescence (e.g., 
Block etal. 1988; Kellam et al. 1983, pp. 17-51; 
Smith and Fogg 1979). The sequence of events 
from childhood to middle adolescence (concep- 
tualized as a progression) appears to be the best 
predictor of early-onset drug use (Patterson et 
al. 1992). This progression is probabilistic — not 
all children go through these stages in exactly 
the same way. For example, a child with mar- 
ginal adjustment in the sixth grade can escalate 
through this sequence of events over the course 
of 2 years, given a family disruption or change 
in community risk factors. 

Schools are the primary setting in which 
children's social and economic future is negoti- 
ated. Children who do not follow rules quickly 
fall behind in academic achievement (Patterson 
et al. 1989). Antisocial children are often dis- 
liked by other children (Coie and Kupersmidt 
1983; Dodge 1983). The combination of under- 
achievement in school and antisocial behavior, 
in fact, may seriously undermine the child's ac- 
ceptance by the peer group (Dishion 1990, pp. 
128-153). 

Children experiencing academic difficulties and 
peer rejection tend to cluster into "deviant peer 
groups" (Dishion et al. 1991), and this process 
begins quite early (Cairns et al. 1988). However, 
in early adolescence, such peer clustering has 
serious implications for early-onset drug use 
(Dishion et al. 1995, pp. 421-471; Oetting and 



Beauvais 1987) and delinquent and violent be- 
havior in adolescence (Dishion, Eddy, et al. 1997; 
Elliott et al. 1985). Exposure to drug use among 
peers is the strongest correlate of early substance 
use. It is often at this point that families with 
troubled adolescents seek treatment, unfortu- 
nately, after the investment in drug-using peers 
has been made. Although change is certainly 
possible, it is often difficult for parents to com- 
pete with the peer socialization process during 
adolescence. 

The structure of the risk progression does not 
unfold in a vacuum. There is considerable evi- 
dence to indicate that it is not so much who the 
parents are but, rather, their parenting skills that 
are critical for understanding risk and protection. 
Researchers are beginning to converge on a defi- 
nition of parenting practices that fall under the 
heading of family management: relationship 
building, limit setting, positive reinforcement, 
monitoring, and problemsolving/negotiation 
(Hawkins et al. 1992; Patterson et al. 1992). 
These parenting practices are not independent 
skills, but highly correlated and mutually syner- 
gistic (Dishion, Li, et al., in press). Regardless 
of ethnicity or family constitution, adults who 
have assumed the parental role and use these fam- 
ily management practices can protect children 
from some of the adverse conditions that lead to 
drug abuse. 

To focus on the central role of parenting in the 
etiology of adolescent drug use does not justify 
blaming parents. A variety of stressful family, 
neighborhood, and community circumstances 
can disrupt positive parenting practices. Paren- 
tal substance use is clearly a risk factor for early- 
onset drug use (Chassin et al. 1986) and may 



Childhood 
Antisocial 
Behavior 



School 
Maladaptation 

(poor achievement, 
peer difficulties) 



Peer 
Clustering 

(peer drug use) 



Early-Onset 
Drug Use 

(by age 15) 



Drug Abuse 

in 

Young 

Adulthood 



FIGURE 1 . A developmental model for adolescent drug abuse 

SOURCE: Adapted and reprinted with permission from Dishion, T.J., 1998. 



88 National Conference on Drug Abuse Prevention Research 



undermine parents' ability to set abstinence as 
the norm for their adolescents. 

Similarly, economic stress associated with his- 
torical events like the Great Depression (Elder 
et al. 1985), recessions (Conger et al. 1992), or 
longstanding patterns of disadvantage (McLoyd 
1990) disrupts parenting, which in turn feeds into 
the risk structure. Parents can buffer the effects 
of such stress, although under some circum- 
stances, the performance of positive parenting 
requires Herculean efforts. 

Cultural stress occurs in a variety of forms and 
affects a growing number of our Nation's fami- 
lies and children. It is difficult for parents to 
bridge the gap between two cultural worlds as is 
often the challenge for Hispanic families 
(Szapocznik et al. 1980). Acculturation can have 
a disruptive impact on parenting. Interventions 
that provide support for parents under these 
stressful circumstances (bicultural training) are 
known to improve family functioning and relate 
to more positive outcomes in children (Sza- 
pocznik et al. 1984). 

A growing number of families are experiencing 
the disruption of divorce and remarriage. These 
events are far from trivial to the lives of chil- 
dren. Family management is clearly a protective 
factor in the context of divorce (Forgatch et al. 
1988, pp. 135-154). How parents handle conflict 
and their ability to prioritize their children's best 
interests by cooperation and negotiation is the 
key factor in explaining why some children re- 
main healthy and successful in the face of seri- 
ous stress (Buchanan et al. 199 1 ; Maccoby et al. 
1990). The number of remarriage transitions is 
linearly related to the level of maladjustment, 
including the use of drugs in childhood and early 
adolescence. However, the use of family man- 
agement practices can dramatically reduce that 
risk (Capaldi and Patterson 1991). 

In light of the rising levels of substance use and 
violence, the role of communities requires ex- 
amination. Unfortunately, much of this research 
does not directly assess such influences in juxta- 
position to what parents are doing to mitigate 
adverse conditions. Pioneering research by Wil- 
son (1980) is a notable exception. This research 
indicated that in high crime areas in inner-city 
London, parental supervision was a key protec- 
tive factor for preventing delinquency. 




FIGURE 2. The central role of monitoring in 
family management 

SOURCE: Adapted and reprinted with permission, 
Dishion, T.J., 1998. 



It is becoming increasingly clear that parental 
monitoring is the foundation of positive family 
management, especially during adolescence 
when children become more independent and 
spend increasing amounts of time away from 
their parents (see figure 2; Dishion and McMahon 
1998; Wilson 1980). To maintain a positive rela- 
tionship, parents need to be aware of the posi- 
tive efforts of their children. 

In this sense, parental monitoring is both directly 
and indirectly related to early-onset drug use. The 
direct relationship is documented in various stud- 
ies showing that poor parental monitoring pre- 
dicts early substance use (Baumrind 1985, pp. 
13-44; Dishion and Loeber 1985). Parental moni- 
toring is also indirectly related to substance use 
via its impact on time spent with peers. Children 
who are not well monitored tend to wander about 
the community, freely selecting places to spend 
time that include drug use and other delinquent 
activities (Patterson and Dishion 1985; 
Stoolmiller 1994). 

In summary, the evidence is clear that parenting 
practices can serve as a protective factor in the 
face of adverse, risky environments. Because of 
this protective role, parenting practices serve well 
as a target for the prevention of adolescent drug 
abuse. 



Advances in Family-Based Interventions 89 



Family Interventions Work 

In general, a distinction should be made between 
interventions that support existing parenting 
competencies and those that target risk factors 
or family dysfunction. As discussed below, these 
two levels of intervention can be integrated. The 
bulk of the more rigorous research involving 
control groups and random assignment focuses 
on interventions that target risk and dysfunction. 

Research has indicated that interventions aimed 
at improving parenting practices result in the re- 
duction of risk factors as well as actual substance 
use in adolescence. Figure 3 summarizes the find- 
ings on the effectiveness of family-based inter- 
ventions. These conclusions are based on the 
assiduous efforts of intervention scientists, most 
of whom are supported in their research by the 
National Institutes of Health. 




Early Childhood 

Oppositional 

Problems 



Middle Childhood 
Antisocial Behavior 



Adolescent Delinquency 



Adolescent 
Substance Use 



FIGURE 3. The science of drug abuse 
prevention 

SOURCE: Adapted and reprinted with permission, 
Dishion, IJ., 1998. 

Early Childhood 

Oppositional problems in the preschool years are 
a precursor to antisocial behavior (Campbell 
1994). Reduction of behavior problems at this 
age has the potential for long-term preventive 
effects. Webster-Stratton (1984, 1990) docu- 
mented that parenting groups that focus on pro- 
viding support for young families, in conjunction 
with skill development, produce marked im- 
provements in observed parent-child interaction 
and teacher ratings of problems in preschool and 
that the positive effects persisted for at least 



3 years after the intervention. Other researchers 
have found that parenting interventions are ef- 
fective in reducing behavior problems in early 
childhood (Dadds et al. 1992). A critical piece 
of the Webster-Stratton program is the develop- 
ment of videotapes that provide examples of 
positive parenting practices. These videotapes are 
so useful to parents that change was observed in 
children's behavior as a function of the video- 
tapes without the help of therapists (Webster- 
Stratton et al. 1988). However, in general mothers 
preferred to use the videotapes in leader-guided 
parent training groups. 

Middle Childhood 

Antisocial and aggressive behavior in childhood 
is a major predictor of adolescent drug use 
(Kellam et al. 1983, pp. 17-51). Interventions 
targeting parenting practices are the most prom- 
ising in reducing antisocial behavior in middle 
childhood (Dumas 1989; Kazdin 1993; Patterson 
et al. 1993, pp. 43-88). The evidence is exten- 
sive, with several impressive studies of effective- 
ness. Patterson (1974) found that parent training 
interventions were effective in reducing antiso- 
cial behavior in the home and at school. Johnson 
and Christensen (1975) revealed that the impact 
of parent training was evidenced in parent per- 
ceptions, direct observations in the home, and 
brief telephone interviews. McMahon and col- 
leagues (1993) found that parents were satisfied 
with parent training. 

The advantage of family-based interventions is 
that the benefits accrue to all family members. 
For example, Arnold and colleagues (1975) docu- 
mented that parent training produced statistically 
reliable changes in the behavior of the siblings 
of the referred child. This finding is particularly 
relevant when we consider that drug abuse and 
serious delinquency tend to run in families. West 
and Farrington (1973) found that 50 percent of 
the crimes in any given community are commit- 
ted by no more than 10 percent of the families 
within them. 

Research by Kumpfer and colleagues (1996, 
pp. 241-267) is supportive of the preventive po- 
tential of the Strengthening Families program. 
This program of research is exemplary with re- 
spect to its applicability and amenability to a wide 
range of families in diverse ecological settings. 



90 National Conference on Drug Abuse Prevention Research 



Adolescence 

It is often asserted that it is necessary to inter- 
vene early if one wants to have a preventive ef- 
fect. Current knowledge suggests that this is 
simply not true and that intervention during ado- 
lescence is critical within an overall prevention 
strategy. If one takes a life-cycle perspective, in- 
terventions with high-risk adolescents can pre- 
vent difficulties in the next generation of young 
children, especially those of teenage parents. 

Harm reduction is an explicit goal of interven- 
tion in the adolescent phase of development. If 
interventions reduce the escalating cycle of drug 
abuse, delinquency, sexual precocity, or exten- 
sive incarceration, it is possible that very real 
negative outcomes could be prevented. From this 
perspective, it is for each developmental phase 
that interventions are designed that reduce risk 
and promote current adaptation and success in 
the next developmental transition (Dishion and 
Kavanagh, in press). 

Results of outcome studies indicate that family- 
based interventions during adolescence are ef- 
fective in reducing current problem behavior and 
future risk (Alexander and Parsons 1973; Bank 
et al. 1991; Henggeler et al. 1986, 1992). The 
data suggest that interventions that promote fam- 
ily management reduce adolescent substance use 
(Bry et al. 1982; Bry and Canby 1986; Friedman 
1989; Henggeler et al. 1997; Lewis et al. 1990; 
Schmidt et al. 1996; Szapocznik et al. 1997, 
pp. 166-190). Thus, contrary to popular miscon- 
ception, behavior does not crystallize in adoles- 
cence and become intractable to family 
intervention. 

To surmise the potential of family-based inter- 
ventions for the prevention of drug abuse, it is 
necessary to consider studies that target not only 
adolescent substance use but also known precur- 
sors, such as behavior problems in early child- 
hood and antisocial behavior in middle 
childhood. Taken together, the data are quite 
strong in favor of family-based approaches. 

Ingredients of Effective 
Family Interventions 

The studies cited previously share a common 
focus on the use of family management skills 



and promoting parents as the leaders of fami- 
lies. In addition, the science of family-based in- 
tervention is converging on the ingredients. In 
short, effective family-based prevention efforts 
should have the characteristics described below. 

Collaborative and Respectful 

Webster-Stratton and Herbert ( 1993) summarized 
collaborative models as including support, em- 
powerment, and expertise and challenging par- 
ents to change and foresee problems and 
setbacks. In the author and colleagues' work in 
parent groups, the parents' rate of "advice- 
giving" was associated with positive change in 
parenting practices. On the other hand, the more 
the therapist taught social learning skills, the less 
parents changed. This finding is consistent with 
those of Patterson and Forgatch (1985), who 
found that when therapists increased their level 
of teaching, client resistance to change followed 
suit immediately. Patterson (1986) initially dis- 
cussed this as a paradox for behavior-oriented 
therapies, where the presumption is that thera- 
pists exercise influence on change via their ex- 
pertise in behavior change technology (e.g., point 
charts, timeouts, etc.). Behavior change is a deli- 
cate process that requires a period of contempla- 
tion regarding the need for change (Prochaska 
and Diclemente 1982). 

Ecologically and Culturally Sensitive 

A major barrier in working with parents is en- 
gagement and collaboration. Professionals in 
schools who try to meet with parent groups at 
night report that the parents simply do not at- 
tend. Parents often drop out of parent training 
programs prematurely, seemingly hopeless about 
their potential for having an impact (Dishion and 
Patterson 1992). 

Parents are sensitive to the dynamics of the en- 
gagement and change process. Szapocznik and 
colleagues (1988) found that home visits prior 
to family therapy were critical to promote en- 
gagement and reduce early dropout. Patterson 
and Chamberlain (1994) reviewed findings on 
optimal strategies for minimizing parent resis- 
tance to change by using "soft clinical skills" 
such as support and empathy, and minimizing 
teaching, directives, or confrontations with the 



Advances in Family-Based Interventions 91 



family. Reframing verbal statements by family 
members regarding the "cause" of the problem 
is critical for change and the engagement of both 
the child and parents in the change process (Rob- 
ins et al. 1996). 

Finally, interventions with parents must be cul- 
turally sensitive (Kumpfer et al. 1996, pp. 241- 
267). For example, families experiencing the 
stress of acculturation need expertise and 
support in this area (Coatsworth et al. 1996, 
pp. 395-404), as well as therapists who are sen- 
sitive to cultural perspectives. 

Flexible Delivery 

As the previous points suggest, in interacting with 
parents in the change process, family interven- 
tion leaders need to be flexible at an interper- 
sonal level. Behavioral family therapy focuses 
on supporting change in the family interaction 
contingencies. However, how that is accom- 
plished varies, is highly flexible, and depends 
on the history and motivation of the parent. In 
many respects, the behavioral therapist is re- 
quired to go "beyond technology" to be success- 
ful in working within a behavioral modality 
(Patterson 1985, pp. 1344-1379). 

Family-based interventions also must be flexible 
with respect to scheduling and locus of the inter- 
vention activity. Spoth and Redmond (1996, pp. 
299-328) have advanced the field by using mar- 
keting research strategies to better understand 
optimal ways of engaging and working with 
families. Families are not inclined to participate 
in family interventions that are led by profes- 
sionals, have more than a 5 -week time commit- 
ment, or involve the school or other parents. 
Despite these preferences, not all parents will 
seek the same intervention services, and there- 
fore it is necessary to offer a wide range of inter- 
vention times and modalities in a variety of 
locations. 

Finally, a rigid focus on parenting issues is not 
as effective as encompassing multiple levels of 
issues that confront and disrupt parenting 
(Henggeler et al. 1986; Prinz and Miller 1994). 
The flexibility of the intervention agenda is con- 
sistent with the principles of effective interven- 
tions for reducing alcohol problems (Miller and 
Rollnick 1991). In general, a menu of interven- 
tion options is more motivating. 



Effective family-based intervention strategies 
interact with parents respectively, supportively, 
and collaboratively. They actively empower par- 
ents to take a leadership role in the family and to 
engage in effective, noncoercive family manage- 
ment practices. It is critical that family-based 
interventions be sensitive to the cultural and eco- 
logical context of the family. 

Family Interventions 
Are Integrative 

To understand the etiology of drug abuse, many 
preventionists are moving toward an "ecologi- 
cal model" design of prevention/intervention 
programs (Henggeler 1993; Szapocznik et al. 
1997). An ecological model proposes that the 
problem of drug abuse does not lie exclusively 
with the individual but is a net outcome of con- 
textual (settings and cultural issues) and indi- 
vidual factors. Research by Pentz and colleagues 
(1989) indicates that comprehensive strategies 
that integrate parenting practices have meaning- 
ful long-term effects. 

Parent interventions should be compatible with 
other intervention strategies and capable of inte- 
gration into more comprehensive community 
intervention programs. Figure 4 summarizes this 




Community-Based Prevention 



FIGURE 4. Integrating families into a 
comprehensive prevention strategy 

SOURCE: Adapted and reprinted with permission, 
Dishion, T.J., 1998. 



92 National Conference on Drug Abuse Prevention Research 



point, making the connections between school- 
based interventions, mentoring programs, recre- 
ation, and academic assistance. 

The key point is that support for family manage- 
ment is at the center of the network. Communi- 
ties need to consider the potential, unintended 
impact of an intervention program on family 
functioning. In general, interventions that inad- 
vertently weaken the leadership role of parents 
or family management practices may have long- 
term negative effects. For example, Szapocznik 
and Kurtines (1989) found that a child-centered 
psychodynamic intervention may have caused 
family functioning to deteriorate. The assignment 
of a college student mentor can undermine a 
single parent who has little available time or re- 
sources. The mentor can take the child to recre- 
ational activities and always be upbeat, 
optimistic, and well rested; the child may make 
negative comparisons of the parent with the new 
mentor, or the parent's authority could be im- 
paired by a mentor's scheduling events with the 
child without coordinating family management 
issues. 

More optimistically, involving parents of high- 
risk youth in prevention activities such as recre- 
ation or clubs is likely to improve the preventive 
effect (St. Pierre et al. 1997). Certainly, integrat- 
ing parents into prevention strategies shows 
promise (Telch et al. 1982). 

If school-based programs ignore the role of par- 
ents in resisting drug use, over time this could 
have a negative impact on parents' collective 
sense of responsibility and empowerment in the 
effort to keep their children safe and healthy. 
Drug education and prevention would become 
the business of the school. It is in this sense that 
health promotion and the prevention of adoles- 
cent drug abuse would be better served by care- 
ful consideration of the critical role of caretaking 
adults in the long-term developmental trajecto- 
ries of children. 

Family Interventions 
Can Be Cost-Effective 

One of the barriers to integrating family inter- 
ventions into community prevention is the 
perceived cost. Yet, analyses of the benefits in- 
dicate that simple parent training is the most 



cost-effective strategy available for the preven- 
tion of crime (Greenwood et al. 1994). One can 
dramatically reduce such cost by matching the 
intervention with the levels of need and risk. 

Several developments indicate that innovations 
in the cost-effectiveness of intervention models 
can be further improved by a focus on motiva- 
tion to change. One development is a reformula- 
tion of the change process in the area of 
addictions. For example, it was found that most 
smokers who quit do so on their own. From this 
line of research, Prochaska and DiClemente 
(1986, pp. 3-27) developed a transtheoretical 
model of change that emphasizes the stages-of- 
change process. The major hurdle is reevaluat- 
ing past behavior and making a decision to 
change and take action. Many individuals go 
through the contemplation-action cycle repeat- 
edly until long-term change is maintained. This 
stages-of-change perspective has been empiri- 
cally tested by Prochaska and colleagues (1991). 

Currently the model serves as a guide to a brief, 
effective intervention with problem alcohol use, 
called motivational interviewing (Miller and 
Rollnick 1991). Motivational interviewing fo- 
cuses on the stages of change by assisting indi- 
viduals in the awareness of the discrepancy 
between their goals and their actual behavior. 
Motivation to change is induced through shar- 
ing of assessment approaches with clients and 
emphasis on support, empowerment, and respon- 
sibility for the behavior change process. The 
"Drinkers Check-Up" is an example of motiva- 
tional interviewing that has been extensively 
tested (Brown and Miller 1993). The "Drinkers 
Check-Up" takes approximately two to three 
meetings with a client, but is superior to inpa- 
tient treatment (typically 28 days) in reducing 
alcohol problems. 

This discussion is important to the design of 
family-based interventions in determining the vi- 
ability of relatively brief interventions. In the next 
decade, a priority for many researchers will be 
to develop and evaluate a range of interventions, 
from brief motivational interventions to inten- 
sive family therapy. 

The author is currently testing a family-based 
multiple gating model that integrates three 
levels of intervention: universal, which targets 



Advances in Family-Based Interventions 93 




f^'/y Intervention (\n&z^ 



rec "t Support for Cha 



Praisal and Motivation f° r 



^Ap Prai , ■ ':-.;: _*,*** 



urce Room 



ettj ng and Information Disse 



Size of Population Affected 




FIGURE 5. A multiple gating model of parenting interventions within a school ecology 

SOURCE: Adapted and reprinted with permission, Dishion, T.J., 1998. 



every person in the population; selected, which 
targets those families defined as at risk; and in- 
dicated, involving more intensive support for 
change for those who have been diagnosed with 
a given disorder. The multiple gating metaphor 
was derived from previous work in multistage 
assessments (Cronbach and Glesar 1965) and 
applied to screening and intervention with prob- 
lem youth (Dishion and Patterson 1992; Dishion 
and Kavanagh, in press; Loeber et al. 1984). Fig- 
ure 5 provides a brief overview of the multiple 
gating model of parent engagement and inter- 
vention. 

The first task in engaging parents in the preven- 
tion of drug abuse is to make an effective link 
between the efforts of the school and the par- 
ents. A Family Resource Center is established 
for that purpose. In an average middle school, 
the prevention activities (available to the entire 
parent population) could be carried out by one 
full-time parent consultant. Research indicates 
that it is the ability to work collaboratively with 
parents, rather than the academic degree, that is 
crucial (Christensen and Jacobson 1994). Thus, 
nonprofessionals or paraprofessionals (with the 



proper training) could staff the Family Resource 
Center. 

Several intervention activities are carried out 
through the Family Resource Center and are in- 
tegrated with the prevention activities of the 
school. School-based curriculums (see Botvin, 
this volume) are often delivered in middle school 
health classes and have shown effects in delay- 
ing the onset of tobacco, marijuana, and alcohol 
use. The author has developed a similar school- 
based curriculum (Teen Focus) that integrates 
interventions for students with brief parent in- 
terventions. All parents of children in the health 
class receive information and engage in exercises 
in family management practices that promote 
positive child outcomes and reduction of the risk 
for early-onset drug use. 

The second level of intervention is the Family 
Checkup. Teachers are highly effective at iden- 
tifying which youths are at risk for future prob- 
lem behavior (see Dishion and Patterson 1992; 
Loeber and Dishion 1983). To reach the second 
level, the Family Checkup service is offered to 
all families in the moderate risk range. For middle 



94 National Conference on Drug Abuse Prevention Research 



school boys, this is determined primarily by their 
social behavior in the classroom and at school. 
For girls, academic failure is an additional indi- 
cator of risk. 

The Family Checkup is a two- to three-session 
evaluation and feedback service that builds on 
the work of Miller and colleagues. Families are 
intensively assessed in their homes (90-minute 
sessions), and the youths are assessed at school. 
Parents are then provided with feedback to build 
motivation to continue those positive family 
management practices that are already in place 
and to improve on those parenting practices or 
circumstances that have been shown to elevate 
the risk of drug use in early adolescence. It is 
essential that the feedback sessions utilize the 
principles described previously for effectively 
working with parents. 

Finally, on the basis of the Family Checkup, a 
small percentage of families (approximately 5 
to 10 percent) will require more intensive sup- 
port for change, along the lines described in the 
work of Bry, Hennegler, and Szapocznik. Sup- 
port for change in family management includes 
daily information regarding the child's atten- 
dance, behavior, and homework completion; 
meetings with the parent consultant to support 
and solve parenting issues; and mobilization of 
community resources to reduce the family dis- 
ruption that interferes with effective parenting. 

This comprehensive model is currently being 
tested in a NIDA-funded prevention trial. Par- 
ticipants include 1,200 youth and their families 
from different racial and ethnic groups. Although 
each of the components described above has been 
shown to be effective, research will extend the 
findings to determine which level of interven- 
tion is indicated for families with varying levels 
of risk. 

Summary 

The etiology of drug abuse is not a mysterious 
accumulation of risk factors, but rather an out- 
come of disrupted parenting. There are widely 
various trends that are stressful for American 
families and that expose children to early-onset 
drug use and potential drug abuse. The use of 



effective family management practices is seen 
as a major protective factor. In this sense, pre- 
vention strategies that promote family manage- 
ment and adult involvement are critical for the 
long-term effectiveness of prevention. The evi- 
dence is clear that mobilization of parents at vari- 
ous developmental stages is likely to be effective 
in reducing risk or harm to children and adoles- 
cents. Developments within the behavioral 
change sciences in general, and within family- 
based interventions in particular, are promising 
with regard to the cost-effectiveness of reaching 
out to parents to collaboratively promote the 
health, success, and well-being of children. 

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100 National Conference on Drug Abuse Prevention Research 



Invited Paper 

Effectiveness of a Culturally Tailored, 
Family-Focused Substance Abuse Program: 
The Strengthening Families Program 



Kami L. Kumpfer, Ph.D. 3 
Health Education Department 
University of Utah 



Introduction 

Providing the support that families need in order 
to raise well-adjusted children is becoming in- 
creasingly important because of escalating rates 
of juvenile crime, child abuse, and drug use. The 
Monitoring the Future study (Johnston et al. 
1996) shows steady increases since 1992 in to- 
bacco use and since 1993 in illicit drug use. One- 
third (34 percent) of high school seniors now say 
they smoked in the past 30 days, and 22 percent 
report smoking daily. In the past year, 40.2 per- 
cent of seniors have used an illicit drug. Mari- 
juana 30-day use rates for seniors have almost 
doubled since 1992, rising from 11.9 percent to 
21.9 percent. 

Although these increases are correlated with the 
immediate precursors of decreased individual 
and peer perceptions of the harmfulness and dis- 
approval of drugs, social ecology model (SEM) 
data suggest that parents have an early influence 
on the developmental pathways toward drug use 
(Kumpfer and Turner 1990/1991). Whereas 
many empirically tested etiological models 
(Oetting 1992; Oetting and Beauvais 1987; 
Oetting et al. 1989; Newcomb 1992, pp. 255- 
297) find that peer-cluster influence is the major 
reason to initiate drug use, parental disapproval 
of drugs is a major reason not to use drugs 
(Coombs et al. 1991). Moreover, parental sup- 
port has been found to be one of the most pow- 
erful predictors of reduced substance use in 
minority youth (King et al. 1992; Dishion et al. 
1995, pp. 421-471). Hansen and associates 



(1987) have found that increased parental super- 
vision is a major mediator of peer influence. 
Models that more finely test the aspects of fam- 
ily dynamics related to youth problem behaviors 
(e.g., antisocial behavior, substance abuse, high- 
risk sex, academic failure) find family conflict 
associated with reduced family involvement at 
Time 1 (Tl) that significantly predicts inadequate 
parental supervision and peer deviance at T2. Ary 
and colleagues (1996) found direct paths from 
parental supervision and peer deviance to prob- 
lem behaviors, suggesting that not all family 
risk processes are mediated by deviant peer 
involvement. 

These etiological research studies suggest that 
parenting and family interventions that improve 
family conflict, family involvement, and paren- 
tal monitoring also should reduce problem be- 
haviors, including substance abuse (Bry 1983, 
pp. 154-171; Mayer 1995). Parenting skills train- 
ing programs are effective in reducing coercive 
family dynamics (Webster-Stratton 1981, 1982; 
Webster-Stratton et al. 1988) and improving pa- 
rental monitoring (Dishion and Andrews 1995). 
Like other researchers (Bry 1996; Dishion 1996; 
Szapoczniket al. 1988), this investigator believes 
improving parenting practices is the most effec- 
tive strategy for reducing adolescent substance 
abuse and associated problem behaviors. 
Strengthening families could significantly reduce 
this increased trend in adolescent drug use and 
other problem behaviors ( Achenbach and Howell 
1993). 



3 Dr. Kumpfer is currently director of the Center for Substance Abuse Prevention. 

Effectiveness of a Culturally Tailored Substance Abuse Program 101 



One type of family support currently gaining in 
popularity is structured interventions for high- 
risk families, such as parent training and family 
skills training. According to the Institute of Medi- 
cine prevention classification scheme of "univer- 
sal" (general population), "selective" (targeted), 
and "indicated" (subjects with identified risks) 
prevention interventions (Gordon 1987; Mrazek 
and Haggerty 1994), the family skills training 
intervention discussed in this paper is classified 
as a "selective" intervention targeting high-risk 
individuals or subgroups. 

CSAP/PEPS Family 
Research Review 

In a review of family intervention research for 
substance abuse prevention, only three family ap- 
proaches appear to meet the National Institute 
of Medicine criteria for "strong level of evidence 
of effectiveness." According to the Center for 
Substance Abuse Prevention (CSAP) Family Pre- 
vention Enhancement Protocol System (PEPS) 
Expert Panel, this review of the research litera- 
ture found that only behavioral parent training, 
family therapy, and family skills training ap- 
proaches to prevention (Center for Substance 
Abuse Prevention 1998) show strong evidence 
of effectiveness in reducing risk factors for drug 
use, increasing protective factors, and decreas- 
ing drug use. Parent education, family support, 
and family education models did not have enough 
research studies with experimental or quasi-ex- 
perimental designs with positive results to war- 
rant qualifying as effective approaches at this 
time, although family support programs appear 
promising (Yoshikawa 1994). 

The multicomponent family skills training ap- 
proach appears to affect the largest number of 
measured family and youth risk and protective 
factors, according to a separate outcome analy- 
sis conducted for PEPS and presented at the 
NIDA family conference (Kumpfer, Wanberg, 
and Martinez 1996). Because multicomponent 
family skills training programs generally incor- 
porate behavioral parent training, children's skills 
training, and behavioral family therapy, they 
address more risk and protective factors than 
other types of therapy. 



Office of Juvenile Justice and 
Delinquency Prevention: 
Family Strengthening 
Research Interventions 

In a 5-year evaluation of more than 500 family 
and parenting programs for the National Insti- 
tute of Justice, Office of Juvenile Justice and 
Delinquency Prevention, the author articulated 
several principles for best practices in family 
programs (Kumpfer 1993; Kumpfer 1997). These 
included selecting programs that are comprehen- 
sive, family-focused, long-term, of sufficient 
dosage to affect risk or protective factors, devel- 
opmentally appropriate, beginning as early in the 
family life cycle as possible, and delivered by 
well-trained, effective trainers. 

The family programs were rated for their dem- 
onstrated impact in reducing risk factors and in- 
creasing protective factors. The top 25 promising 
programs were published in Strengthening 
America 's Families (Kumpfer 1994b), which was 
rated as one of the top 25 family programs. The 
University of Utah staff won a rebid of this 
project, which included a new national search 
for model family programs, dissemination 
through two national conferences and training 
workshops in many exemplary and model fam- 
ily programs, and technical assistance in imple- 
menting these programs. These model programs 
and a literature review are available on the project 
Web site (http//www-medlib. med.utah.edu/ 
healthed/oj j dp . htm) . 

Family-focused interventions appear to be more 
effective than either child-focused or parent-fo- 
cused approaches. Child-only approaches, not 
combined with parenting or family approaches, 
can have a negative effect on family functioning 
(Szapocznik and Kurtines 1989; Szapocznik 
1997). If high-risk youth are aggregated, dete- 
riorated youth behaviors can occur (Dishion and 
Andrews 1995). Reviews of early childhood pro- 
grams (Dadds et al. 1992; Mitchell et al. 1995; 
Yoshikawa 1994), elementary school-age 
children's programs (Kazdin 1993; Kumpfer and 
Alvarado 1995, pp. 253-292; Patterson et al. 
1993, pp. 43-88), and adolescent programs (Cen- 
ter for Substance Abuse Prevention 1998; 



102 National Conference on Drug Abuse Prevention Research 



Szapocznik 1997) support the effectiveness of 
family-based interventions. In fact, a number of 
adolescent family programs have found signifi- 
cant reductions in substance use (Henggeler et 
al. 1995; Lewis et al. 1990; Szapocznik 1997). 
In recent years there has been a shift from focus- 
ing therapeutic activities primarily on the child 
to improving parents' parenting skills and to rec- 
ognizing the importance of changing the total 
family system (Szapocznik 1997; Parsons and 
Alexander 1997). 

Newly developed family-focused skills training 
programs are more comprehensive and include 
structured parent skills training, children's so- 
cial skills, and parent/child activities, sometimes 
called behavioral family therapy, behavioral par- 
ent training, or family skills training. The new 
family skills training approaches often offer ad- 
ditional family support services, such as food, 
transportation, child care during sessions, advo- 
cacy, and crisis support. 

A few examples of these structured family-fo- 
cused interventions include the Strengthening 
Families program (SFP) (Kumpfer et al. 1989), 
which is effective with substance-abusing par- 
ents and parents from racial and ethnic minority 
groups (Kumpfer, Molgaard, and Spoth 1996); 
Focus on Families (Haggerty et al. 1991) for par- 
ents on methadone maintenance therapy 
(Catalano et al. 1997; Gainey et al. 1997) the 
Nurturing Program (Bavolek et al. 1983) for 
physically and sexually abusive parents; Fami- 
lies and Schools Together (FAST) (McDonald 
et al. 1991) for high-risk students in schools; and 
Family Effectiveness Training (FET) (Sza- 
pocznik et al. 1985). 

Other researchers are employing these broad- 
based family skills programs as part of even more 
comprehensive school-based intervention strat- 
egies. The Fast Track program (Bierman et al. 
1996; McMahon et al. 1996), one of the largest 
prevention intervention research projects funded 
by the National Institute of Mental Health 
(NIMH), is one exemplary program. This selec- 
tive prevention program, implemented with high- 
risk kindergarten students with risk factors such 
as conduct disorders, is being implemented in 
several different sites in the Nation with a large 



team of nationally recognized prevention special- 
ists. Fast Track includes behavioral parent train- 
ing. Parents were found to be satisfied with this 
type of parent training, which involves therapist 
coaching and interactive practice between the 
parent and the child (McMahon et al. 1993). 

One distinguishing feature of these new parent 
and child skills training programs is that they 
provide structured activities in which the curricu- 
lum addresses improvements in parent-child 
bonding or attachment (Bowlby 1969/1982) by 
coaching the parent to improve play time with 
the child during a "Child's Game." This "special 
therapeutic play" has been found effective in 
improving parent-child attachment (Egeland and 
Erickson 1987, pp. 110-120; Egeland and 
Erickson 1990). Using intervention strategies 
developed by Kogan and Tyler (1978) and Fore- 
hand and McMahon (1981), parents learn 
through observation, direct practice with imme- 
diate feedback by the trainers and videotape, and 
trainer and child reinforcement on how to im- 
prove positive play (Barkeley 1986), by follow- 
ing the child's lead and not correcting, bossing, 
criticizing, or directing. Teaching parents thera- 
peutic play has been found to improve parent- 
child attachment and child behaviors in 
psychiatrically disturbed and behaviorally dis- 
ordered children (Egeland and Erickson 1990; 
Kumpfer, Molgaard, and Spoth 1996). These 
family programs encourage family members 
to increase family unity and communication and 
reduce family conflict as found in prior SFP 
studies. 

Strengthening Families Program 

Theoretical Model Underlying SFP 

The importance of a family approach to substance 
abuse prevention is based on an empirically 
tested model called the social ecology model of 
adolescent substance abuse (Kumpfer and Turner 
1990-1991). This structural equation model of 
the precursors of drug use, derived from com- 
prehensive data on 1,800 high school students, 
suggests that family climate or environment (see 
figure 1) is a root cause of later precursors of 
substance abuse. The family influences the 



Effectiveness of a Culturally Tailored Substance Abuse Program 103 



F = Females 
M= Males 




FIGURE 1 . Social ecology model of adolescent alcohol and other drug (AOD) use 

SOURCE: Adapted and reprinted with permission. Kumpfer, K.L., and Turner, C, International Journal of the 
Addictions, 1991. 



youth's perceptions of the school climate, school 
bonding and self-esteem, choice of peers and 
deviant peer influence, and eventually substance 
use or abuse. Strong, positive relationships be- 
tween child and parents create supportive, trans- 
actional processes between them that reduce the 
developmental vulnerability to drug use (Brook 
et al. 1990; Brook et al. 1992, pp. 359-388). 
Additional empirically derived models of the 
precursors of drug use also support the influence 
of the family (Newcomb et al. 1986; Newcomb 
1992, 1995;Swaimetal. 1989). 

The content of the SFP family intervention is 
based on empirical family research that eluci- 
dates a risk and protection or resilience frame- 
work presented by the author at the 1994 NIDA 
Resilience Conference (Kumpfer 1994a). The 
primary family risk factors include parent and 
sibling drug use, poor socialization, ineffective 
supervision and discipline, negative parent-child 
relationships, family conflict, family stress, poor 
parental mental health, differential family accul- 
turation, and poverty (Kumpfer and Alvarado 
1995). 

Family protective factors (Kumpfer and Bluth, 
in press; Kumpfer, in press a) include one caring 
adult (Werner 1986; Werner and Smith 1992), 
emotional support, appropriate developmental 
expectations, opportunities for meaningful fam- 
ily involvement, supporting dreams and goals, 
setting rules and norms, maintaining strong 



extended family support networks, and other pro- 
tective processes. The probability of a child's 
developing problems increases rapidly as the 
number of risk factors increases (Sameroff et al. 
1987; Rutter 1987) relative to the number of pro- 
tective factors (Dunst 1994, 1995; Dunst and 
Trivette 1994, pp. 277-313; Rutter 1993). Chil- 
dren and youth generally are able to withstand 
the stress of one or two family problems in their 
lives; however, when they are continually bom- 
barded by family problems, their probability of 
becoming substance users increases (Bry et al. 
1982; Newcomb et al. 1986; Newcomb and 
Bentler 1986). Future SFP content revisions will 
include more emphasis on resilience principles. 

Overview of Prior 
SFP Research Studies 

The Strengthening Families Program (Kumpfer 
et al. 1989) is a highly structured, 14- week, com- 
prehensive family-focused curriculum. It in- 
cludes three conjointly run components: parent 
training, children's skills training, and family 
skills training. Each 2.5- to 3-hour session is led 
by two cotrainers. The SFP for elementary 
school-age children of drug abusers was origi- 
nally developed and evaluated between 1982 
and 1985 (with 3 years of NIDA funding) 
employing a randomized phase III controlled in- 
tervention trial. 



104 National Conference on Drug Abuse Prevention Research 



This paper discusses the original NIDA positive 
results and subsequent SFP replications with 
minor modifications for African- American fami- 
lies in Alabama and Detroit and multiethnic fami- 
lies in three counties in Utah. All of the 
replications to date have reported similar posi- 
tive results on the parents' and children's behav- 
iors and drug use (Aktan 1995; Aktan et al. 1996; 
Sherwood and Harrison 1996; Harrison, 
Proskauer, and Kumpfer 1995; Kameoka and 
Lecar 1996; for a review of all studies, see 
Kumpfer, Molgaard, and Spoth 1996 or Kumpfer, 
in pressb). Positive results on intervention-tar- 
geted behaviors have been reported by Spoth and 
colleagues (in press) for a seven-session version 
of SFP (Molgaard et al. 1994). This SFP variant 
was based on resilience principles and developed 
for sixth-grade students in rural Iowa. It was 
tested in a 5 -year, NIMH-funded randomized 
clinical trial in 20 counties in Iowa by Spoth at 
Iowa State University. The preliminary immedi- 
ate session outcomes also look promising, with 
significant improvements in parenting attitudes 
and beliefs as well as significant increases in fam- 
ily meetings (Kumpfer, in press b). In addition, 
Spoth (1997) reported on positive outcome re- 
sults for reductions in tobacco and alcohol use 
rates among youth participating in the program. 

Original NIDA SFP 

Research Design and Subjects 

The original NIDA-funded research was de- 
signed to reduce vulnerability to drug abuse in 
children of patients on methadone maintenance 
therapy and substance-abusing outpatients from 
community mental health centers. The experi- 
mental design tested the impact of a parent train- 
ing program only, a children's training program 
added to the parent training program, and a fam- 
ily skills training and relationship enhancement 
program added to the other two components com- 
pared with no-treatment controls. In this experi- 
mental dismantling design, families were 
randomly assigned to either a 14-session SFP par- 
ent training program based on Patterson's (1975, 
1976) parent training model; the combined SFP 
parent training program and SFP children's skills 
training program based primarily on Spivack and 
Shure's (1979) social skills training; or a three- 
part combination of the prior two programs plus 
the SFP family skills training program based on 



Forehand and McMahon's (1981) program de- 
scribed in their book, Helping the Noncompliant 
Child, and Bernard Guerney's Family Relation- 
ship Enhancement Program. The sample of 208 
families consisted of 7 1 experimental interven- 
tion families, 47 no-treatment families matched 
on 8 demographic characteristics to the treatment 
families, and 90 general population comparison 
families. 

Program Content 

Both parents and children attend separate classes 
for the first hour and then work together in fam- 
ily sessions in the second hour. A third hour is 
spent in logistics, meals, and family fun activi- 
ties. The underlying concept is to have the par- 
ents and children separately learn their skills or 
roles in a family activity and then come together 
to practice those family skills. To increase re- 
cruitment and retention, a number of incentives 
were developed by the various sites implement- 
ing the program, as recommended by Kumpfer 
(1991), including meals and snacks, transporta- 
tion, rewards for attendance and participation 
(drawings, tickets, or vouchers for sporting, cul- 
tural, educational, and family social activities; 
movies, dinners, groceries, clothing, household 
items, and children's Christmas gifts), a nursery 
for child care of younger siblings, older adoles- 
cent recreation, and support/tutoring groups. 

• The Parent Training Program sessions in the 
original SFP included group-building, teach- 
ing parents to increase wanted behaviors in 
children by increasing attention and reinforce- 
ments, behavioral goal statements, differen- 
tial attention, chore charts and spinners (pie 
charts with sections representing rewards 
mutually decided on that children may get if 
they complete all chores), communication 
training, alcohol and other drug education, 
problemsolving, compliance requests, prin- 
ciples of limit-setting (timeouts, punishment, 
overcorrection), generalization and mainte- 
nance of limit-setting, and implementation of 
behavior programs for their children. 

• The Children's Skills Training Program in- 
cluded a rationale for the program, commu- 
nication of group rules; understanding 
feelings; social skills of attending, communi- 
cating, and ignoring; good behavior; 



Effectiveness of a Culturally Tailored Substance Abuse Program 105 



problemsolving; communication rules and 
practice; resisting peer pressure; questions and 
discussion about alcohol and other drugs; 
compliance with parental rules; understand- 
ing and handling emotions; sharing feelings 
and dealing with criticism; handling anger; 
and resources for help and review. 

• The Family Skills Training Program sessions 
provided a time for the families to practice 
their skills (with trainer support and feedback) 
in the Child's Game (Forehand and McMahon 
1981), a structured play therapy session with 
parents trained to interact with their children 
in a nonpunitive, noncontrolling, and positive 
way. 

Research and observation have shown that dys- 
functional, antisocial, and drug-abusing parents 
are limited in their ability to attend to their 
children's emotional and social cues and to re- 
spond appropriately (Hans 1995); hence, the four 
sessions of Child's Game focused on training 
parents in therapeutic parent-child play. The next 
three sessions of Family Game meetings trained 
parents and children to improve family commu- 
nication. Four sessions of Parents' Game focused 
on role-plays during which the parents practiced 
different types of requests and commands with 
their children. The beginning session focused on 
group-building, introduction to content of pro- 
gram, contracting, and brainstorming possible 
solutions to barriers to attendance. The 13th ses- 
sion focused on generalization of gains and con- 
necting to other support services; the 14th session 
was a graduation celebration. A testing session 
before and after the program meant the families 
actually attended for 16 weeks, although the 
training program was 14 weeks long. 

NIDA SFP Outcome Results 

An extensive multi-informant, multisource in- 
strument battery of parental, child, and therapist 
report measures (including both parents or care- 
takers, therapists, and all target children) was 
employed to assess improvements of hypoth- 
esized risk and protective factor outcomes, in- 
cluding the Child Behavior Checklist (CBCL) 
(Achenbach and Edelbrock 1988), Cowen Par- 
ent Attitude Scale (Cowen 1968), and the Fam- 
ily Environment Scale (FES) (Moos 1974). 
Analysis of the baseline, pretest data indicated 



that children of substance abusers in treatment 
have significantly more behavioral, academic, 
social, and emotional problems than a matched 
comparison group of children of parents who 
are not substance abusers or children in the gen- 
eral population (Kumpfer and DeMarsh 1986, 
pp. 49-89). 

Outcome results using analyses of variance 
(ANOVAs) to compare the four different treat- 
ment groups suggest that the combined interven- 
tion that included all three components was the 
most powerful in improving the child's risk sta- 
tus in three theoretically indicated and interven- 
tion-targeted areas: 

• Children's problem behaviors, emotional 
status, and prosocial skills 

• Parents' parenting skills 

• Family environment and family functioning 
(improved family communication, clarity of 
family rules, nonconflictive sibling relation- 
ships, decreased family conflict, and less 
social isolation). 

In general, the pattern of results suggests that 
each program component was effective in reduc- 
ing risk factors that were the most directly tar- 
geted by that particular component. For example, 
the parent training curriculum significantly im- 
proved parenting skills and parenting self-effi- 
cacy, the children's skills program improved 
children's prosocial skills, and the family pro- 
gram improved family relationships and envi- 
ronment. Use of tobacco and alcohol by older 
children was reduced, as well as expectations of 
alcohol and tobacco use by those nonusing chil- 
dren. Parents also reduced their drug use and 
improved in parenting efficacy (DeMarsh and 
Kumpfer 1986, pp. 117-151). Although the 
children's social skills increased with exposure 
to the Children's Skills Training Program in the 
parent-training-plus-child-training condition, the 
improvements in negative acting-out behaviors 
were not as good as that found for the Parent 
Training Program only. This result, plus the re- 
cent similar results of Dishion and Andrews 
(1995), calls into question the potential value of 
high-risk child-only groups because of possible 
negative contagion effects and smaller effects on 
improving risky youth behaviors. 



106 National Conference on Drug Abuse Prevention Research 



CSAP Replication Studies 

Because of these positive NIDA SFP results, 
agencies in five States have been successful in 
attracting demonstration/evaluation research 
funding from CSAP. These five grants involved 
eight different community agencies with high- 
risk ethnic population families, including [two] 
studies with African-American families. Both of 
these studies — the Alabama State Department of 
Mental Health and Mental Rehabilitation study 
of low-income African-American drug-using 
mothers in rural Alabama and the Detroit City 
Health Department's study of inner-city African- 
American drug abusers — have published final 
positive results (Aktan 1995; Aktan et al. 1996; 
Kumpfer, Molgaard, and Spoth 1996; Kumpfer, 
in press b). Additional studies with low-income 
Hispanic families from housing complexes in 
Denver (Wanberg and Nyholm 1998), Asian/Pa- 
cific Islander and Latino families in three coun- 
ties in Utah (Harrison and Proskauer 1995), and 
Asian and Pacific Islander families in Hawaii 
(Kameoka and Lecar 1996) demonstrate similar 
significant improvements in the children and 
families participating in SFP programs. A study 
of a language-modified and culturally modified 
SFP for high-risk French-Canadian families, 
which is funded by the Canadian government, is 
in its third year, and a new culturally modified 
SFP for Australian families was developed and 
implemented by the author. 

These studies significantly demonstrate that SFP 
can be successfully implemented with ethnic 
families and that the dropout rates are low 
(15 percent) after the first few cohorts (Aktan 
1995). The results for the African- American 
families only are summarized below. (See 
Kumpfer, Molgaard, and Spoth [1996] for a more 
detailed description of results.) 

African-American SFP Results 

Rural African-American SFP 

The Alabama SFP program, implemented with 
62 families in Selma, AL, by the Cahaba Mental 
Health Center, compared low-drug-using fami- 
lies (alcohol use only) to high-drug-using fami- 
lies (alcohol plus illicit drug use) in a 
quasi-experimental pretest, posttest, and 1-year 
followup design. Most (82 percent) of the fami- 
lies completed at least 12 of the 14 sessions. 



Results showed that high-drug-using mothers not 
in drug treatment reduced their drug use (on a 
composite index of 30-day alcohol and other drug 
quantity and frequency of use), family conflict 
decreased, and family organization increased. 
Before the program began, the children of the 
high-drug-using mothers compared with children 
of low-drug-using mothers had significantly 
more (according to the CBCL) internalizing be- 
havior problems (e.g., depression, obsessive- 
compulsive behavior, somatic complaints, social 
withdrawal, uncommunicative demeanor, and 
schizoid scales) and externalizing behavior prob- 
lems (e.g., aggression, delinquency, and hyper- 
activity). By the end of the program, the children 
of high-drug-using mothers were rated as sig- 
nificantly improved on both the internalizing and 
externalizing scales and all subscales, except the 
"uncommunicative" subscale. Children of low- 
drug-using mothers improved only on the clini- 
cal scales for which they manifested relatively 
higher scores on the intake pretest, namely ob- 
sessive-compulsive behavior, aggression, and 
delinquency. SFP was equally effective for less 
educated and better educated mothers in improv- 
ing the parenting style and behaviors of the chil- 
dren. 

Urban African-American Families 

The Safe Haven Program of the Harbor Light 
Salvation Army and the Detroit City Health De- 
partment is a 12-session SFP modified for inner- 
city African-American families. This program 
demonstrated similar positive results with 51 
families by the end of the second year. Results 
showed significantly improved family relation- 
ships and family organization, reduced family 
conflict, and increased family cohesion. This in- 
crease in family cohesion, which was not found 
in Alabama, may have occurred because the Safe 
Haven program put more emphasis on reuniting 
the mothers and fathers as a total family. The 
families did report spending more time together. 
Also, the parents reported that parent-and-child 
activities increased as well as the amount of time 
that the parent and child spent together. 

Parents reported a decrease in drug use, depres- 
sion, and use of corporal punishment and an 
increase in their perceived efficacy as par- 
ents. According to parental reports, children's 
externalizing problem behaviors decreased 



Effectiveness of a Culturally Tailored Substance Abuse Program 107 



significantly in aggression and hyperactivity and 
approached a significant decrease in delinquent 
behaviors. Significant improvements from pre- 
test to posttest were found only for the children 
of the high-drug-using parents in terms of re- 
duced school problems and less general inter- 
nalization of problems. There was also a 
reduction in more specific measures of depres- 
sion and social withdrawal and in uncommuni- 
cative, obsessive-compulsive, and schizoid 
behaviors. Parents in both groups reported in- 
creased school bonding, more children's time 
spent on homework, and no significant unin- 
tended negative effects. These parent reports 
matched the therapists' reports on behavioral 
improvements in the participating families. 

Utah Community Youth Activity 
Project (CYAP) SFP Research 

The Utah State Division of Substance Abuse 
tested SFP in three counties and eight agencies 
that serve ethnic populations in a quasi- 
experimental pretest, posttest, and 3-month 
followup design comparing SFP to Communi- 
ties Empowering Parents Program, a local pro- 
gram with no family skills training. A total of 
421 parents and 703 high-risk youths (ages 6 to 
13 years) were recruited to attend one of the two 
programs. On the pretest, 57 percent of the youth 
had behavioral and academic problems. The to- 
tal sample included 33 percent fathers, 59 per- 
cent mothers, and 8 percent guardians or foster 
parents from 49 percent single-parent families, 
66 percent low-income families, 69 percent fami- 
lies from ethnic populations (26 percent Asian, 
20 percent Pacific Islander, 18 percent Latino, 
and 5 percent Native American youth), and 50 
percent families with little or no religious in- 
volvement. The program materials for both pro- 
grams and the instrument battery were translated 
into Spanish, Vietnamese, Tongan, Korean, and 
Chinese for this project. Attendance and comple- 
tion rates for the program were high, averaging 
85 percent across the three county sites. 

Data Analysis 

The analysis of the pretest and posttest change 
scores suggested improvements in family envi- 
ronment, parenting behaviors, and children's 
behaviors and emotional status. Significant 
pretest-to-posttest reductions in the youths' 



problems were reported by the SFP parents on 
all CBCL subscales and composite externaliz- 
ing and internalizing scales, but on only two of 
the FES scales for family conflict and cohesion. 
SFP was significantly more effective than the 
comparison program. 

Five-Year Followup Study 

A 5 -year followup study of the participants in 
this three-county Utah CYAP/SFP study 
(Harrison 1994) included 87 families confiden- 
tially interviewed by a research psychiatrist from 
Harvard University. The results (Kumpfer, 
Molgaard, and Spoth 1996) suggested that, even 
after 5 years, a substantial percentage of fami- 
lies were still using the family management skills 
that had been taught. Family meetings once per 
month were reported by 68 percent of the fami- 
lies, and 37 percent conducted them weekly. The 
adults reported lasting improvements in family 
problems (78 percent), stress/conflict levels 
(75 percent), amount of family fun (62 percent), 
family talking together more (67 percent), and 
showing positive feelings (65 percent). Analy- 
ses revealed a gradual decline in the frequency 
of use of family skills taught in the program; 
however, the researchers (Harrison 1994) con- 
cluded, "The change figures show that a major- 
ity of families maintain lasting improvements, 
even over a 5-year period." 

Strengthening Hawaiian 
Families Program 

In Hawaii, the Coalition for a Drug-Free Hawaii, 
headed by Lecar, has revised the SFP to be more 
culturally appropriate for Hawaiian-Asian and 
Pacific Islander cultures. The Strengthening Ha- 
waiian Families (SHF) Program has a 20-session 
curriculum that emphasizes awareness of family 
values, family relationships, and communication 
skills. To increase parental readiness for change, 
a 10-session family and parenting values curricu- 
lum precedes the 10-session SFP family 
management curriculum. The revised curriculum 
covers topics such as connecting with one an- 
other, caring words, generational continuity, cul- 
ture, communication, honesty, choice, trust, 
anger, problemsolving, decisionmaking, and 
stress management. An audiotape and videotape 
accompany the curriculum manuals. 



108 National Conference on Drug Abuse Prevention Research 



An independent evaluation was conducted by the 
University of Hawaii (Kameoka and Lecar 1996) 
using a quasi-experimental, pretest-posttest, 
nonequivalent control group design to evaluate 
the effectiveness of hypothesized outcome vari- 
ables to program objectives. The original 14-ses- 
sion SFP implemented in four sites in fall 1992 
was compared with the 20-session, culturally 
revised SHF program implemented in nine sites 
between spring 1994 and winter 1995. 

The measurement battery was culturally modi- 
fied by alteration of words and expressions not 
common in Hawaii and comprised several dif- 
ferent tests, including the 53-item Brief Symp- 
tom Inventory (BSI) (Derogatis and Lazarus 
1994, pp. 217-248) and the Center for Epidemio- 
logical Studies-Depression Scale (CESD) 
(Radloff 1977) rather than the Beck Depression 
Inventory (BDI) (Beck etal. 1961). Only the 113- 
item Teacher's Report Form (TRF) (Achenbach 
1991) was used rather than the parent CBCL 
version. Teachers were paid $5 to complete and 
return the form to the evaluator in a stamped 
envelope. The same 49-item substance use mea- 
sure (Kumpfer 1987, pp. 1-88) was used as the 
original SFP testing battery as well as the four 
10-item subscales of the FES (cohesion, expres- 
siveness, conflict, and organization) and two 
subscales of the Adult- Adolescent Parenting In- 
ventory (AAPI) (Bavolek 1985) on physical pun- 
ishment and inappropriate expectations. A third 
subscale on parents' use of positive reinforcers 
was developed by the evaluator (Kameoka and 
Lecar 1996). 

Because of high attrition (48 percent), low at- 
tendance rates, and lack of risk-level equivalence 
of the experimental and comparison groups, the 
results of the outcome evaluation must be inter- 
preted with caution. Small sample sizes (19 SFP 
subjects, 52 SHF subjects), reduced risk at pre- 
test compared with drug treatment samples in 
other studies, and switching to a values-based 
curriculum versus a social learning theory-based 
family and social skills training curriculum all 
contributed to lower power and effectiveness. 
This program was interpreted by the evaluator 
as an "educational program designed for 
nonclinical populations"; hence, participants re- 
ceiving professional services were eliminated 
from the data analysis, yet they may have ben- 
efited the most. 



Because of the nonequivalence of the compari- 
son and experimental groups, only the signifi- 
cant pretest and posttest changes are reported 
here. Both the SFP and SHF programs attained 
their goal of strengthening family relationships 
and resulted in significant improvements in fam- 
ily cohesion and family organization, and in re- 
ducing family conflict. However, significant 
improvement was reported for expressiveness or 
communication. Only the original SFP resulted 
in statistically significant improvements in atti- 
tudes and skills in rewarding positive behaviors. 
The largest mean improvement for physical pun- 
ishment was for the original SFP, but because of 
low numbers and high variance, this positive re- 
sult can be reported only as a nonsignificant 
trend. 

Similarly, the original SFP appeared to be more 
effective in reducing parental depression than 
was the culturally modified SHF; SFP resulted 
in positive changes in somatization, interpersonal 
problems, anxiety, hostility, phobias, and para- 
noia, whereas the SHF program affected only 
hostility and paranoia in addition to depression. 

Substance use decreased in SFP participants for 
parents, siblings, and children but use increased 
significantly for SHF among children and non- 
significantly for parents. No significant improve- 
ments were found in children's behaviors as rated 
by their teachers from pretest to posttest. 

Strengthening Hispanic 
Families Program 

The Denver Area Youth Services (DAYS) has 
been involved in modifying the SFP for increased 
local effectiveness primarily with Hispanic chil- 
dren and families in several inner-city housing 
projects. These are the families shown in the 
NIDA videotape "Coming Together on Preven- 
tion" (National Institute on Drug Abuse 1994). 
Preliminary results suggest that the DAYS staff 
has been successful in attracting and maintain- 
ing these high-risk families in SFP. Between 
September 1992 and January 31, 1996, SFP and 
a child-only Basic Prevention Program (BPP) 
comparison intervention had been implemented 
with 311 clients. Twenty-five percent of refer- 
rals came from schools and other community 
agencies, but the balance of 75 percent came from 



Effectiveness of a Culturally Tailored Substance Abuse Program 109 



DAYS aggressive outreach efforts in housing 
complexes. 

One of the major successes of this program was 
the high program completion rate of 92 percent, 
based on the criteria of a participant's attending 
at least 70 percent of all sessions and participat- 
ing in the graduation ceremony to receive a cer- 
tificate of completion (Kumpfer, Wanberg, and 
Martinez 1996). The mean age of the children 
was 8.4 years (range 5 to 12 years) with 53 per- 
cent boys and 47 percent girls. Single-parent 
homes accounted for 75 percent of the children, 
with 30 percent of the mothers reporting that they 
were never married to the biological father. Most 
participants were from low-income families, with 
a mean family income of $6,700. The manuals 
were substantially modified, and Spanish trans- 
lation versions provided for Spanish-language 
families. 

The Strengthening Hispanic Families Program 
is being evaluated by Wanberg and Nyholm 
(1998). Careful attention to retention in the 
folio wup design has resulted in 87 percent of the 
families completing the 6-month followup and 
75 percent completing the 1-year followup. A 
relatively low level of risk factors is being re- 
ported for these children, possibly because this 
program is not selecting for children of substance 
abusers like the original NIDA research or the 
other Utah, Alabama, and Detroit studies. 

Baseline data suggest that the major increase in 
exposure to tobacco, alcohol, and other drugs 
occurs in the lives of these Hispanic children 
between age 8 and 9 years. As in the Utah stud- 
ies, many of the children (33 percent) report be- 
ing sad or depressed, with 28 percent saying they 
have thoughts of hurting themselves or commit- 
ting suicide. As many as 20 percent of these el- 
ementary school children are having difficulties 
with school adjustment, and 44 percent have been 
involved in fistfights. 

The child and parent satisfaction and perceptions 
of usefulness of the two comparison programs 
were almost identical, although parents rated SFP 
slightly higher except in the areas of the child's 
"doing better at school" and "making friends," 
for which parents rated SFP about 20 percent 
higher (65 percent vs. 46 percent). The children 



participating in each program rated both 
programs about the same in usefulness. 

Rural Families of 

Junior High School Students 

Researchers at Iowa State University have de- 
veloped a seven-session modification of SFP for 
junior high school students that is based on re- 
siliency principles (Kumpfer, in press a), called 
the Iowa Strengthening Families Program (ISFP) 
(Molgaard, Kumpfer, and Spoth 1994). Research 
on this program was conducted with NIDA and 
NIMH funding for a phase III experimental in- 
tervention trial (Greenwald and Cullen 1985; 
Jansen et al. 1996) that compared 33 randomly 
assigned schools from 19 contiguous rural coun- 
ties with either the ISFP and Preparing for the 
Drug-Free Years program (PDFY) (Hawkins et 
al. 1994) or no-treatment control schools. 

Program Design 

Like the original SFP, ISFP includes parenting 
and youth sessions in the first hour and a family 
session in the second hour. Parents are taught 
the importance of encouraging and supporting 
dreams, goals, and resilience in youth; provid- 
ing appropriate expectations and discipline; en- 
gaging in effective communication with preteens; 
handling strong teen emotions; implementing 
family meetings to improve family togetherness, 
family organization, and planning; and determin- 
ing family rules and consequences for breaking 
family rules. The children's sessions generally 
parallel the parent sessions and cover resilience 
with dreams and goals, stress and anger man- 
agement, and social skills (such as communica- 
tion, problemsolving, decisionmaking, and 
peer-refusal skills). The family sessions engage 
the participants in activities to increase the aware- 
ness of youth and family goals, increase fam- 
ily cohesion and communication, and reduce 
family conflict. 

ISFP was implemented in winter 1994 with 
161 families from 21 ISFP groups from 11 
schools, but only 114 families completed the pre- 
test and were included in the data analysis. The 
average group size was 8 families and ranged 
from 3 to 15 families, with about 20 parents and 
children attending each session. Approximately 



110 National Conference on Drug Abuse Prevention Research 



94 percent of pretested participants completed 
at least five or more sessions, 88 percent attended 
at least six sessions, and 62 percent attended all 
seven sessions. Despite the use of the total 
parenting program videotape to help standard- 
ize the implementation as well as reduce the cost 
of the second trainer, fidelity observations of at 
least two sessions showed that 83 percent of the 
content of the parent training session was cov- 
ered, 87 percent of the family session, and 89 
percent of the youth skills training session. Spoth 
(in press) reports in more detail on the recruit- 
ment and retention rates for Project Family con- 
taining ISFP and PDFY. 

Data were collected during a 2- to 2.5-hour in- 
home session using both questionnaires and in- 
cluding a number of standardized measures and 
three videotaped tasks, each lasting 15 minutes. 
The topics for the tasks included general ques- 
tions about family life (such as approaches to 
parenting and household chores) that were dis- 
cussed independently with either the mother and 
the child or the father and the child, selected ran- 
domly and then switched. In a second task, the 
family members discussed sources of disagree- 
ment determined previously by a checklist. The 
families were paid $10 per hour for the testing 
time. 

ISFP Results 

The preliminary session-by-session results were 
analyzed for comparison of the immediate be- 
havioral intentions to change with actual changes 
(see Bry et al., in press, for additional discussion 
on these data). Overall, the data suggest a num- 
ber of significant behavioral changes by the 
mothers and fathers from session to session that 
matched the actual objectives of the sessions. 
There are differential effects on mothers and fa- 
thers, related primarily to differences in baseline 
behaviors. Hence, fathers and mothers appear to 
change in those behaviors where they have more 
room for improvement. 

The preliminary outcome data from the in-home 
video coding of family interaction patterns and 
the self-reported changes on the annual family 
assessments show significant improvements. 
Although the comparisons of each of the mea- 
surement scales have not yet been reported, Spoth 



and associates (in press) report significant pre- 
test and posttest improvements in all hypoth- 
esized effects for both ISFP and PDFY, 
employing a "group code approach" for small 
sample structural equation models discussed by 
Aiken and colleagues (1994). This approach uses 
a common measurement model for both the ex- 
perimental and control groups and includes a 
group code variable. 

The major advantage of this type of SEM is that 
half as many parameters are required as for the 
multigroup approach, making this analysis attrac- 
tive for smaller sample sizes relative to the num- 
ber of parameters estimated. A finding of no 
statistically significant intraclass correlations as- 
sociated with outcome measures indicated that 
family-level rather than school-level analyses 
would be appropriate despite the nested research 
design of families within randomly assigned 
schools. Spoth (in press) reports more on the pre- 
liminary results; however, at this point, the three 
hypothesized structural effects (parent-child af- 
fective quality, intervention-targeted behaviors, 
and general child management) appear to be sta- 
tistically significant at both pretest and posttest 
at the .01 level when conducting an SEM analy- 
sis on data from 178 ISFP and 179 control group 
families (N=357). 

Summary of SFP 
Outcome Results Across 
Diverse Ethnic Populations 

The original NIDA SFP and the later Iowa SFP 
randomized control research provides strong evi- 
dence of the effectiveness of SFP with white 
families. Because of employing only quasi- 
experimental designs, the replication studies pro- 
vide only weak, but consistently positive, sup- 
port for SFP effectiveness for other ethnic groups. 
The effect sizes were quite large, as determined 
in a power analysis, in fact statistically signifi- 
cantly larger, for the higher risk families than for 
the lower risk families. However, the repeated 
replications with external evaluators suggest that 
SFP can be implemented by others with integ- 
rity and fidelity. 

This is partially because the SFP manuals and 
training of trainers are very specific and detailed. 



Effectiveness of a Culturally Tailored Substance Abuse Program 111 



The SFP trainings require the staff members who 
will be doing the training to prepare several ses- 
sions from the manuals and deliver them to the 
group whose members role-play typical parents 
or children. Time is spent in processing group 
dynamics and discussing how to most effectively 
deal with participant issues that could arise from 
the program session content. Therefore, the train- 
ers learn the total content of the program, see 
many different delivery styles, and learn how to 
deal with group dynamics. 

The positive program results are consistent across 
the sites implementing the program even when 
different evaluators have evaluated the program. 
Six different independent research evaluations 
have been conducted by university-based re- 
searchers in three departments at the University 
of Utah. In addition, researchers at the Univer- 
sity of Hawaii, Case Western University, Harvard 
University, and the University of Colorado have 
evaluated the program on cultural modifications. 
One doctoral dissertation (Millard 1993) that 
addressed high-risk, general population families 
recruited through schools also supported the posi- 
tive results. Because SFP appears to be rather 
robust in terms of consistently favorable results 
across multiple replications with culturally di- 
verse populations, NIDA selected SFP as an ex- 
ample of a selective prevention program for its 
Drug Abuse Prevention Package (NIDA 1997). 
An implementation manual and videotape, 
"Coming Together on Prevention," are available 
from the National Clearinghouse for Alcohol and 
Drug Information (Kumpfer, Williams, and 
Baxley 1997). 

Research Issues and 
Recommended Future Family 
Intervention Research 

Because of the small amount of past funding, 
many family research projects conducted only 
"black box" research designs to determine over- 
all effectiveness in comparison with control 
groups. In addition to an emphasis on examina- 
tion of program effectiveness for different cul- 
tural and ethnic groups, more refined research 
questions should determine: 



The most effective program components 

Effectiveness of family programs compared 
with child-only programs 

Duration of effectiveness using longitudinal 
designs and booster sessions 

Best recruitment and retention methods 

Who benefits most by conducting analyses 
by client demographic or risk factor covariates 

Implementation variables in health services 
research 

Cost-benefit of programs 

Why some communities and agencies are 
more ready than others to implement family 
programs or can do so with fidelity and 
increased effectiveness. 

Research on Relative Effect 
Sizes of Components of 
Family-Focused Interventions 

Few family-focused prevention programs have 
examined the different components of their pro- 
grams to determine the differential effectiveness 
of components on different risk and protective 
factors. The Strengthening Families Program in 
the original NIDA research study did use a dis- 
mantling design to examine the comparative ef- 
fectiveness of a parent training program only 
(PT); PT plus children's social skills program 
(CT); PT, CT, and a family skills training pro- 
gram (FT); and a no-treatment control group. 
Using this four-group randomized design, the 
investigators (Kumpfer, Molgaard, and Spoth 
1996) found that the combined program (FT) was 
most effective, but each component was most 
effective in changing the variables it was de- 
signed to affect. Hence, the children's program 
improved the children's social skills; the parent 
training program improved the parent's parenting 
skills and parenting self-efficacy, discipline 
methods, and children's acting-out behaviors; 
and the family program improved the family's 
communication, organization, and support- 
iveness. It would be helpful to have a more in- 
ternal examination of component effectiveness 
in other family programs. 



112 National Conference on Drug Abuse Prevention Research 



Research on Family-Focused Versus 
Child-Focused Interventions 

Major questions still exist in the research litera- 
ture (Kumpfer, in pressb) about whether to fo- 
cus scarce prevention resources on the child-only, 
parent-only, or total-family approach. Many pre- 
vention providers prefer to work only with chil- 
dren in school or community programs. Family 
intervention researchers (Szapocznik 1997) 
strongly believe that to have a lasting positive 
effect on the developmental outcomes of a child, 
it is essential to improve the family ecology or 
context by creating more nurturing and support- 
ive parent-child interactions. Parental support 
and guidance by prosocial, well-adjusted parents 
provide a sustaining positive influence on 
children's developmental trajectories and risk 
status for drug use. Although peer influence ap- 
pears to be the final pathway to drag use as found 
in many etiological studies (Kumpfer and Turner 
1990/1991; Newcomb 1992, 1995; Swaim et al. 
1989), the primary reason not to use drugs ap- 
pears to be positive family influence (Coombs 
etal. 1991). 

There also is suggestive evidence that bringing 
a group of at-risk youth together in a child-only 
group creates a negative contagion effect 
(Gottfredson 1987). Dishion and Andrews (1995) 
randomly assigned 119 at-risk families with 11- 
to 14-year-olds to one of four intervention con- 
ditions: parent-focus-only, teen-focus-only, par- 
ent-and-teen focus, and self-directed change. 
Results showed positive longitudinal trends in 
substance use in the parent-focus-only group, but 
suggestive evidence of negative effects in the 
teen-focus-only condition. These results stressed 
the importance of involving parents and reevalu- 
ating strategies that aggregate high-risk youth, 
particularly in groups where insufficiently trained 
staff cannot control and improve group norms 
or influence. Social learning theory (Bandura 
1986) suggests that youth need exposure to posi- 
tive adult role models, such as parents and group 
leaders, who can provide opportunities for youth 
to learn behavior skills and social competencies 
and for exposure to higher levels of moral think- 
ing (Levine et al. 1985). 

In addition, in the original 1982-1985 NIDA SFP 
research (DeMarsh and Kumpfer 1986; Kumpfer 
and DeMarsh 1986; Kumpfer 1987, pp. 1-71), 



evidence suggested that increased exposure to 
high-risk peers with poor social competencies 
and moral reasoning reduced the positive gains 
in youth negative behaviors from the SFP parent 
training, although positive social skills increased 
more. This critical research and practice ques- 
tion has not been addressed with children 
younger than 11 years. 

Longitudinal Studies of Family 
Intervention Effectiveness 

The long-term effectiveness of family programs 
should be examined by means of improved 
longitudinal design and recently developed meas- 
urement and data analysis technologies. Unfor- 
tunately, there was no long-term followup funded 
in the original 3-year NIDA research study. The 
positive results were based on only the pretest 
and posttest changes in the youth and parents. A 
5-year followup (Harrison et al. 1995) of SFP 
was implemented on a three-county Utah State 
grant funded by CSAP. Even though the abbre- 
viated interview survey data collected suggest 
amazing longevity of positive family function- 
ing and maintenance of principles and behaviors 
taught in the SFP, the data collection did not in- 
clude the full parent and youth outcome assess- 
ment battery so critically needed to determine 
the true long-term impact on youth drug use. 

Best Methods for Recruiting and 
Retaining High-Risk Families 

Many prevention practitioners believe that it is 
"monumentally discouraging" to work with fami- 
lies and that they are almost impossible to re- 
cruit and maintain in family interventions. This 
is partially true, particularly in the first cycle of 
implementing the program, before the "bugs" are 
worked out and the staff becomes more compe- 
tent, but many family skills training interven- 
tions, including the SFP, report retention rates of 
around 82 to 85 percent (Kumpfer, Molgaard, 
and Spoth 1996; Aktan 1995; Aktan et al. 1996; 
McDonald 1993). 

Few family researchers have conducted system- 
atic examinations using strategies of recruitment 
and attrition factors essential to successful pro- 
gram implementation. One notable exception is 
Spoth and associates (1996) from Iowa State 
University, who evaluated engagement and 



Effectiveness of a Culturally Tailored Substance Abuse Program 113 



retention using marketing research strategies on 
data from the Iowa Strengthening Families Pro- 
gram. They have conducted many studies on the 
ISFP, including the following: 

• A prospective participation factor survey 
(Spoth et al. 1995) found that perceived pro- 
gram benefits and barriers were strong pre- 
dictors of inclination to enroll and that stated 
inclination to enroll and parent education level 
were the strongest predictors of actual 
participation. 

• A refusal survey (Spoth et al. 1 996) found that 
time and scheduling conflicts are major rea- 
sons to refuse to participate, as is gender (fa- 
thers see less benefit in family interventions 
than mothers). 

• A risk by participation and retention analysis 
found no differential participation or attrition 
for higher risk families in contrast to com- 
mon assumptions about the difficulties of at- 
tracting and retaining high-risk families 
(Center for Substance Abuse Prevention 
1995). 

Additional research is needed on special recruit- 
ment methods to attract and retain high-risk fami- 
lies, as discussed by Kumpfer (1991) in 
Parenting Training Is Prevention. Methods used 
to reduce barriers to recruitment and to retain 
high-risk families for many selective prevention 
programs like SFP include child care, transpor- 
tation, meals, payments for testing time, gradua- 
tion completion gifts, prizes for completion of 
homework, and small gifts (pencils, pens, stick- 
ers) for the children, earned with good behavior. 
Special family outings or retreats are also major 
attractions in family programs that increase 
family participation. 

Who Benefits Most 

From Family Interventions? 

In addition to addressing component effective- 
ness, family-focused intervention research 
should be directed toward a better understand- 
ing of intrafamily variables such as which types 
of clients benefit most by the different interven- 
tion components. Hence, it is possible that the 
different components of SFP will be differentially 



effective with different types of parents and 
youth. As did prior studies (Aktan et al. 1996), 
future studies should include outcome 
subanalyses by participant covariates to deter- 
mine whether family interventions are more or 
less effective for different types of participants 
using post hoc, statistical quasi-experimental 
analyses, as recommended by Cook and 
Campbell (1979). These covariant analyses could 
examine program effectiveness by program site, 
multiethnic status, parental drug use, parental 
depression, educational status, parent and child 
gender, single- versus two-parent families, pa- 
rental criminal status, and child's baseline level 
of risk and protective factor status. 

Methods for Improving 
Program Implementation: 
Health Services Research 

Most NIH research institutes, including NIDA, 
have a separate set-aside for health services re- 
search that examines questions related to improv- 
ing the implementation and dissemination of 
model research-based programs. Researchers of 
model family programs should consider research 
designs that will allow them to examine and an- 
swer these important program implementation 
questions as subaims of their studies. These 
subaims can be examined through planned com- 
parisons of process data linked to outcome data 
across the experimental groups to examine re- 
search questions concerning differential recruit- 
ment and attrition rates by demographic client 
variables (e.g., gender, education level, ethnic 
status) and program components; variables lead- 
ing to increased program involvement; differen- 
tial consumer satisfaction and participation rates 
compared to outcomes; factors related to fidel- 
ity of the program implementation across sites; 
impact of trainer variables (e.g., years of experi- 
ence, delivery competence, perceived warmth 
and supportiveness by clients and evaluators) on 
program process and outcome variables; and 
other agency and staff variables recorded in 
forcefield analyses (Gottfredson 1986) affecting 
implementation quality. A strong process evalu- 
ation is needed to examine these important 
subaims. 



114 National Conference on Drug Abuse Prevention Research 



Need for Cost-Effectiveness 
and Cost-Benefit Studies 

Pentz (1993) and the staff at NIDAhave strongly 
encouraged prevention programs to collect and 
report cost data. Conducting comparative cost- 
benefit analyses on major prevention interven- 
tions would help providers make better decisions 
about where to allocate scarce resources. There 
is little literature documenting the cost benefit 
or cost-effectiveness of drug abuse prevention 
because of difficulties measuring and devising 
monetary values for comparative prevention in- 
tervention outcomes (Kim et al. 1995). Accord- 
ing to Apsler (1991, pp. 57-66), there have been 
no rigorous cost-effectiveness studies of drug 
prevention or treatment. The only published cost- 
effectiveness study (Hu et al. 1981) comparing 
different types of drug prevention (alternative, 
education, intervention, and information) con- 
tained no control group. An analysis of the ben- 
efits of different crime prevention strategies 
suggests that parent training is the most cost-ef- 
fective strategy for the prevention of delinquency 
(Greenwood et al. 1994). Because of the overlap 
of etiological precursors of delinquency and drug 
use, it is highly likely that the most cost-effec- 
tive strategy for drug abuse prevention is also 
family-focused approaches. 

Benefit-cost analyses are easier to calculate be- 
cause they require no control groups or compari- 
son of interventions. Although Russell (1986) 
challenged the economic benefits of health pro- 
motion and prevention programs, Kim and asso- 
ciates (1995) calculated that the benefits of drug 
prevention exceed costs by a ratio of 15 to 1. 
Kristein (1997) reported a benefit-cost ratio of 
1.8 to 1 for smoking cessation programs, and a 
larger ratio of 2.3 to 1 for employee assistance 
programs for alcohol misuse. 

As discussed by Plotnick (1994), the program 
benefits in a cost-effectiveness analysis should 
be based on the magnitude of the statistically sig- 
nificant differences or effect sizes between the 
different programs by context and mediating and 
outcome cluster variables. The costs saved (ben- 
efits) attached to reductions in negative youth 
outcomes can be calculated for direct costs (e.g., 
medical, criminal, productivity, community ser- 
vice, and opportunity) with use of national eco- 
nomic cost data (Rice et al. 1991), local cost 



estimates for drug use and drug-related legal sys- 
tem costs, economic costs (loss of productivity), 
and medical costs; and indirect costs as recom- 
mended by French and associates (1991) and 
used by French and Zarkin (1992) for TOPS. 
Prospective service utilization rates (e.g., medi- 
cal, mental health, legal, and community services 
in the prior year) can be collected from program 
participants on regular pretest and annual posttest 
questionnaires to determine alternative explana- 
tions for program effects and also for benefit 
analyses. 

Readiness of Communities and 
Agencies To Implement 
Family Programs Effectively 

The readiness of communities and agencies or 
schools to implement family programs can dif- 
fer widely and affect their implementation suc- 
cess. Any researcher with access to many 
different sites interested in implementing family 
programs should consider a research design that 
allows for examination of variables in the com- 
munity and agencies that would affect readiness 
to implement model research programs with fi- 
delity and effectiveness. A review of factors af- 
fecting community readiness and ways to 
enhance community readiness for prevention 
programs is available in a new publication from 
NIDA, Assessing and Enhancing Community 
Readiness for Prevention (Kumpfer, Whiteside, 
and Wanders man 1997). 

Lack of Research Funding for Family- 
Focused Prevention Approaches 

Prevention programs have typically targeted 
young people in school-based, universal ap- 
proaches. Over the years, a few family interven- 
tion approaches have been supported by NIDA 
and NIAAA, notably those of family programs 
developed by Drs. Alvey, Bauman, Hawkins and 
Catalano, Dielman, Dishion, Kumpfer, 
Szapocznik, and Zucker. Because of a major ini- 
tiative at NIDA to support family-focused pre- 
vention efforts, and the increasing frustration of 
school-based researchers [trying] to get long- 
lasting and powerful effects, a number of new 
family research projects have been funded to Drs. 
Molberg and McDonald, Eggert, Whitbeck, and 
Spoth. The results from these research grants 



Effectiveness of a Culturally Tailored Substance Abuse Program 115 



may help to strengthen support for this family 
approach. 

Most of the funding for family-focused selec- 
tive prevention programs has come through foun- 
dation or CSAP demonstration or evaluation 
initiatives, which generally do not require re- 
search designs with random assignment of sub- 
jects. The selective prevention approaches that 
have been rigorously evaluated have shown posi- 
tive impact on many risk factors (see Goplerud 
1990; Center for Substance Abuse Prevention 
1993; Kumpfer 1997; andLorion and Ross 1992, 
for reviews of effectiveness of many selective 
prevention programs for drug abuse prevention). 

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124 National Conference on Drug Abuse Prevention Research 



CONCURRENT SESSIONS 



Work Group Discussions 



Introduction 

Each of the five science-based topics presented 
at the plenary session formed the focus of a work 
group: Risk and Protective Factors, Critical Fac- 
tors for Prevention Success, Prevention Through 
the Schools, Prevention Through the Commu- 
nity, and Prevention Through the Family. Each 
work group was moderated by a NIDA staff per- 
son and included a panel consisting of a scien- 
tist from the plenary session, a National 
Prevention Network (NPN) State representative, 
and a community leader. 

The work groups opened with the NPN repre- 
sentative and the community leader each giving 
a 5-minute response to the scientific presenta- 
tion given during the plenary session. These in- 
dividuals discussed their impressions of the 
session and how they thought the information 
could be relevant to their situation as a State or 
community representative. They also were asked 
to respond to the following questions: 

• What did you think about what was said? Did 
the findings fit with your perception of the 
nature of the problem and proposed solutions? 

• Is it feasible for you in your position to do 
something with this information? 

• Did these findings suggest changes you could 
make to programming at your level? 

• What are the barriers to doing so? What un- 
tapped resources could be put to these efforts? 

• Do you have suggestions on how to facilitate 
the implementation of these types of pro- 
grams? 

Following this presentation, the scientist on each 
panel was asked to comment on these issues and 



to clarify his or her presentation from the ple- 
nary session. The panel members then led a dis- 
cussion with work group members about specific 
implementation or application issues, in addition 
to answering any audience questions about the 
topic. Additional questions to be explored with 
work group participants during this discussion 
included the following: 

• How would you go about utilizing or imple- 
menting the information gleaned from this 
session? 

• Who are the key community people who 
would have to be involved for successful uti- 
lization or implementation, such as the school 
system, mayor's office, etc.? 

• Are these types of interventions financially 
feasible for your community? 

• Is your community aware of the rising trends 
in adolescent drug use, and if not, how can 
you raise awareness to attract the support that 
you need for your programs? 

• What suggestions or insights do you have 
from the policy or practice arena that could 
further the science in this area? 

• How do you access research findings on pre- 
vention? Are these findings in a useable for- 
mat? What would be helpful to you on an 
ongoing basis? 

• What about the future? What new areas of 
research would help you in your work? What 
are your information needs? Are there par- 
ticular topics of research or information that 
you need? 

Issues and recommendations for research and 
practice were recorded and reported by the panel 



Concurrent Sessions 125 



scientists during the open forum on the second 
day of the conference. 

Work Group on Risk and 
Protective Factors 

Panel: 

Robert J. Pandina 
Rutgers University, NJ 

Sherry T. Young 

National Prevention Network, UT 

Carol N. Stone 

Regional Drug Initiative, Portland, OR 

Moderator: 

Meyer Glantz 

National Institute on Drug Abuse 

Sherry Young 

We were asked to address what was said during 
this morning's presentations. I have to point to 
Dr. Leshner's talk when he defined prevention 
as a process of educational and behavioral change 
and the realization, as Dr. Pandina stated, that 
risk and protective factors are not fixed and are 
subject to change. Those two things are what we 
need to talk about when we talk to States, coun- 
ties, and communities because that is the most 
simplistic way I have heard anyone explain this 
research, which actually becomes pretty compli- 
cated, or appears to be complicated. 

I would like to have heard more from Dr. Pandina 
about the community, as well as the individual, 
in risk and protective factor research. I learned 
something new from his discussion of markers, 
modifiers, and mediators. In Utah, we are using 
the research findings to influence changes at the 
State, county, and community levels. We also are 
working with the Department of Human Serv- 
ices, under which our Division of Substance 
Abuse falls, the State Office of Education, Crimi- 
nal and Juvenile Justice, and most recently, the 
Department of Corrections, in learning how this 
research can be applied to services. It is impor- 
tant to see what attitudes and behaviors will work 
across the board. 

Barriers, as Dr. Leshner stated, are important. We 
do not always say the same things or sing the 
same song. I have noticed in Utah, but not solely 



in Utah, that some people in the field of sub- 
stance abuse prevention contradict what this re- 
search says about risk and protective factors. 
They sometimes influence others to discount the 
research on risk and protective factors. I was 
happy to hear Dr. Botvin say that we must iden- 
tify what puts the children and schools at risk. I 
have heard people interpret his research differ- 
ently, so it is good to hear him explain that. People 
in the field who contradict research tend to be 
selective about what they present, and they most 
often leave out the risk part of risk and protec- 
tive factors. 

We still do not know enough. We always want to 
know more, and we are not doing as good a job 
as we could in disseminating the information that 
we have. I would encourage NIDA to continue 
to increase support to those who collect the data 
and who understand the benefits of this as a sci- 
ence and how important this research is in de- 
veloping credible prevention systems. 

Carol Stone 

I am glad to see that there are people here who 
are with community coalitions. I will address the 
information that I received today from the com- 
munity coalition perspective. First of all, I did 
not hear anything today that was not useful or 
will not be useful to me when I get back home to 
Portland. It certainly fits our perceptions in terms 
of the work we have done and our perceptions 
of the nature of the problems and their solutions. 
There are pieces coming from the community 
coalition perspective. There are pieces of this 
work that we and other community coalitions 
across the country are involved in and can sup- 
port that we did not hear about today. But we 
certainly can support some of the things that we 
have heard discussed. 

We have heard that the most effective preven- 
tion programs are school based. From a commu- 
nity coalition perspective, there is certainly no 
argument with that. But there is a lot that a com- 
munity coalition can do to build resiliency fac- 
tors, change policies, and change the social 
environment that will support those school-based 
prevention programs. I can give you examples 
of that. 



126 National Conference on Drug Abuse Prevention Research 



A community coalition is one that pulls together 
the leadership from across all sectors in the com- 
munity, including the health care community, 
faith community, government leaders, business 
community, prevention and treatment programs, 
and schools. They pull together everybody so that 
there is widespread community support for pre- 
vention and so that, as Dr. Leshner said this morn- 
ing, there is truly an environment that is created 
so everyone can "sing the same song." That is 
absolutely crucial. One of the reasons the Re- 
gional Drug Initiative was formed in Portland 
10 years ago was because the schools were say- 
ing, "Do not leave this all to us. We really need 
some more help on this issue." 

In addition to a community coalition supporting 
what is already in existence, there is much more 
of an opportunity for making policy changes. In 
most community coalitions — and there are thou- 
sands of them in the United States — there is a 
real commitment on the part of coalition mem- 
bers to make changes within their spheres of in- 
fluence. I have seen this in Portland with the 
3,000 employers we have worked with on drug- 
free workplace programs. This is one of the com- 
ponents that can support what is going on in the 
schools. 

Drug-free workplaces can be sites for parent 
training, parent gatherings, parent support, and 
getting parents more information about how to 
set limits in their own homes. In Oregon this year 
we have seen some tragic results of parents who 
have lost children — and it seems like this year 
has been a particularly bad year — because they 
thought it was okay to send their son or daughter 
to a keg party that was being sponsored by friends 
who they thought were responsible. Or they 
thought it was responsible to host a keg party for 
their high-school-age children, and it simply is 
not responsible, as we all know. 

There are other kinds of things that community 
coalitions can do, for instance, including youth 
in presenting the messages and in becoming posi- 
tive peer influences, as well as having them be 
part of changing that whole social environment 
and helping to build resiliency factors. 

I think it is certainly feasibile to work with this 
information. I know that I personally am going 
to take some of the latest research information 
we have heard and start looking at ways to 



update coalition members. It seems that there is 
constantly more information to learn. There has 
been some validation of several programs I have 
seen that deal with family management problems. 
I know that there is an excellent one in Oregon 
that is based on family interventions, working 
with the schools, working with families, and 
working with employers. It is based on building 
family strengths. 

In looking at barriers that we are facing, identi- 
fying high-risk kids is really touchy and can be 
damaging, even though there is a real need to 
make sure that we offer prevention programs in 
all areas where there is risk. 

There certainly is always a need for continued 
funding. More than anything, and I hear this all 
over the country, there is a real need to fund the 
evaluation of program results. It is difficult to 
prove that what you are doing works without that 
evaluation. For some reason, evaluations are not 
something that people usually want to pay for. 

The other idea that was touched on briefly was 
the political reality of going for the hard policy 
changes within a community that might decide 
that they cannot support you any more because 
you are too outspoken and you are trying to make 
changes that are too radical. 

Robert Pandina 

One of the biggest gaps that this conference is 
trying to address is the need for people like me 
and people like you who do prevention trials re- 
search to meet together in the same room to dis- 
cuss what scientists have to offer. I mean this 
seriously — we work for you. The big problem 
is finding a forum or venue where we can meet 
together. 

In New Jersey, we have a large community coa- 
lition program, and at our university we are try- 
ing to work with both our State and Governor's 
Council. The basic mechanism is to bring these 
groups together to have a real exchange of infor- 
mation. We have a certain kind of information to 
give you, but you also have a certain kind of in- 
formation to give us that probably will enrich 
our ability to develop the models you need. 

In all honesty, and I have said this at other fo- 
rums, the real challenge is not to take $1 million 
and deliver an intervention service to 100 kids. 



Concurrent Sessions 127 



The real challenge is to take $100 and find a way 
to provide an intervention model for 1 million 
kids, because that is more realistic at the com- 
munity level. The other thing that I hope will 
come out of this conference is a recognition that 
we who do this research, which sometimes is 
thought of as rather esoteric, do have an appre- 
ciation for your efforts and are working hard to 
bring you useful information. Also, by commu- 
nicating together, you can tell us from your per- 
spective what you need so that we can help you 
adapt what we find at the research bench and 
implement it at the community level. 

With regard to evaluation within the community 
perspective, we have fought hard to develop 
evaluation strategies within the basic science and 
applied science milieu. We are now at another 
stage in evaluation development. That is, trying 
to develop evaluation designs that can be applied 
to programs at the community level that do not 
traditionally fit the clinical trials mode. It is a 
real challenge. More than once we have been 
called in by people who want to know whether 
they are being effective in a program that is al- 
ready operating. They ask us to evaluate it, and 
we have $100 with which to do that. You can 
appreciate the complexity of the research that you 
saw today and the resources that are necessary 
to do these kinds of evaluations. We need to de- 
velop an evaluation model that can be extended 
to the communities, but that is going to take a lot 
of thinking on our part and a lot of adaptation. I 
think that is a tool that we need to develop, and 
we are going to need your help to develop it. We 
need to find common ground or common ways 
of communicating with one another, and I think 
we are much closer to it than we have ever been 
before. 

In a way, I believe that the building blocks are in 
place now. Conferences like this are an attempt 
to get us together to find a way to forge ahead on 
several levels: first, to exchange information so 
you can take what we now know and apply it in 
a practical sense, and second, to figure out how 
we can develop evaluation models and learn 
more about what your needs are. 

I do not do prevention trials research as such. So 
when I hear what you are saying and I look at 
the community-level risk factors, I am concerned 
about how to take what we know about risk 



factors and give them to your community alli- 
ances so that you can use that information to 
change your communities. There is no question 
that risk factors can be identified in the commu- 
nities. Risk factors come in all sizes and shapes, 
and identifying them requires everything from 
understanding the nature of the community to 
understanding where the real community lead- 
ership is and how one can affect the leadership. 

I will give you one example. My colleagues 
Nancy Boyd Franklin, who is an African- 
American woman doing work on family inter- 
ventions, and Brenda Bry have been able to con- 
tact a group in a New Jersey township that is 
heavily African-American in terms of its culture 
and its investment in the faith community. They 
have had tremendous success in developing a 
drug prevention intervention involving the faith 
community and working from that group back 
to the schools to which they could not gain ac- 
cess. Because the faith community was strong 
in that community and because they could mo- 
bilize the community leadership, they were able 
to identify a resilience factor, a way of gaining 
access to the schools and developing a school- 
based, faith-based, and general community pro- 
gram. This would not have been possible if they 
had not recognized the strengths and weaknesses 
in the community and if they had not used the 
strengths within the faith community to reach the 
schools. 

So when I talk about things like the availability 
of prosocial activities in schools and communi- 
ties and the social norms, attitudes, and avail- 
ability of support for prosocial values, I do not 
mean just in the school or the family but wher- 
ever you can find them in the community. The 
generic principles that I talk about can be ap- 
plied at any level of analysis, including the com- 
munity level, when looking at factors like 
prosocial values or the availability of construc- 
tive after-school activities. 

More should be done to identify those kinds of 
factors, and a different kind of paradigm should 
be developed for learning how to intervene at 
the community level, because it can have an in- 
credibly powerful influence. However, research- 
ers, and especially prevention scientists, typically 
have a difficult time getting into the communi- 
ties where the real leadership exists. It is hard to 



128 National Conference on Drug Abuse Prevention Research 



identify and meet community leaders, but we 
need to talk to these leaders so that we can tailor 
prevention programs to fit the needs of specific 
communities. 

Risk and protective factors may be the same, but 
how one implements prevention programs may 
be quite different in different communities. One 
must be very creative about that. This is one of 
the next areas where prevention programs must 
go. After all, schools do not necessarily define 
the community. Communities are defined by 
many more factors, including the generic fac- 
tors that I listed in my presentation. 

For example, in New Jersey we have two places 
where kids meet — cemeteries and malls. When- 
ever I think we are doing very well in some pre- 
vention arena, I go to the different malls in New 
Jersey and sit in the parking lots, typically near 
the entrance to the movie theaters. In this way I 
can get some estimate of what is going on in that 
community. We need to do something in this 
venue because this is where the kids are. Some- 
one said today that one of the reasons to use 
school-based programs is because that is where 
the kids are. But the kids are also in other places, 
and that is where they do the kinds of things that 
are considered to be high-risk behaviors. 

You will notice that I never talked about "high- 
risk kids" today. I cannot think in those terms 
because it does not make sense to chop up the 
world that way. It is more a question of the fac- 
tors to which some kids may be exposed. Ge- 
neric risk and protective factors and those models 
go well beyond individual and biological issues 
and can be specified and identified at the com- 
munity and State levels. 

Our coalition has been very effective in convinc- 
ing our Governor that resources ought to be set 
aside and distributed at the community level. One 
of the problems I see in that approach is that they 
need the technology to know what community 
programs to choose so that those dollars go as 
far as possible. 

These are different kinds of approaches, but they 
fit well within the risk-and-protective-factor 
model. You have to be a little bit more general- 
ized in thinking about that, and a little bit cre- 
ative about extending yourself in that model, but 
it works very well. 



A community, in a way, is an organism. It is made 
up of parts. Those parts fit together, and there is 
an outcome based on those parts. There is a dy- 
namic in the community. 

I think this kind of science can go a long way to 
helping with that kind of analysis. I would still 
offer that the risk factor approach starts with an 
analysis of those factors and how they operate. 
From that will flow the ability to pick out the 
menu of what we have from either family-based 
programs or school-based programs and adapt 
them to the communities. The principles are the 
same. They sound different, but they can be gen- 
eralized to extend very nicely to the community, 
the State, or for that matter, the regional level. 

Work Group on Critical Factors 
for Prevention Success 

Panel: 

William B. Hansen 
Tanglewood Research, Inc. 

Barbara Groves 

Oregon Together, Oregon Office of Alcohol 

and Drug Abuse Programs 

Betty S. Sembler 
Operation PAR, FL 

Moderator: 

William Bukoski 

National Institute on Drug Abuse 

Barbara Groves 

In Oregon, we have a two-tiered focus. We have 
county prevention funding and resources, and we 
have local community coalitions, which we call 
the Oregon Together Project, that began as part 
of the Hawkins and Catalano research in 1988. 
We have been doing the risk-and-protective- 
factor focus framework since 1988 and have been 
collecting data since that time. We are thinking 
about using all of the prevention strategies, in- 
formation dissemination, and prevention educa- 
tion, and we also are looking strongly at 
collaborations. We do a lot of networking with 
the Department of Corrections and the Depart- 
ment of Education. We just started this year 
involving managed care organizations in preven- 
tion. We have written into our contracts that 



Concurrent Sessions 129 



managed care organizations have to provide drug 
abuse prevention services. 

We are working on the risk and protective fac- 
tors with other organizations, including Warm 
Springs, our largest Native American reservation, 
which also has a Robert Wood Johnson Founda- 
tion grant. We are working to connect with that 
community and elaborate on what they are do- 
ing at the local level. 

Our community contracts and county-based con- 
tracts require that they supply us with the pre- 
vention framework that they are using. We 
require all of our funded projects and programs 
to have an identified structure. It does not have 
to be the risk-and-protective-factor focus frame- 
work, but it does have to be research based. 

We also require in our contracts that evaluation 
outcomes be identified. We require that the pro- 
jected outcomes be described, and we monitor 
those outcomes over time. The bottom line is that 
we are trying to help the communities learn to 
sustain themselves. As we all know, Federal fund- 
ing is diminishing all the time, and, certainly, 
State funding is not great. In Oregon, all of our 
prevention program funding is Federal funding. 
We do not get a dime of general fund dollars for 
prevention. Therefore, we are especially inter- 
ested in trying to develop community resources. 
In fact, a lot of our local communities tell us that 
the dollars are not as important as the other re- 
sources we can bring to the table. 

New communities that we are working with are 
the Asian- American and Pacific Islander Ameri- 
can communities in Portland. We are having to 
relearn how to do prevention with them. It is dif- 
ferent than working with the Native American 
or African- American communities, and it does 
not necessarily fit the social development mod- 
els. So we are doing some different things, learn- 
ing from them, and taking our lead from them. 

As a State agency, we see our job as bringing the 
resources to the table and working as a partner. 
We are trying hard not to dictate and tell every- 
one what to do and to give them the flexibility. 
We want to be able to answer their questions, 
bring them resources, strengthen local capabili- 
ties, and truly be a partner with them. We see 
that as our primary function in addition to coor- 
dinating with other State agencies. 



We are working with local children, the Com- 
mission on Children and Families, and juvenile 
justice, and they are all talking about risk and 
protective factors. We are all using the same lan- 
guage now. 

We are coordinating budgets, staff people, and 
evaluation requirements so that one community 
does not have to report on one contract one way 
and develop a totally different report for another. 
We have been working hard on that in the past 
2 years. 

Collaboration is key. As folks have said, we are 
not all dancing at the dance, but we are in the 
same ballroom. Some of us are doing the rumba, 
and some of us are doing the jitterbug. But we 
all realize we need to be there together and that 
there are different ways to work on prevention 
as long as we all know the basic framework and 
have the access to the information. I think one 
of the biggest barriers is that most of our people 
at the community level are volunteers, but that 
is the nature of prevention [work]. 

Most people in Oregon truly believe that evalu- 
ation is important. I do not think folks are ques- 
tioning that anymore, but how to do it is the issue. 
The minute they hear evaluation, they get con- 
fused about research and data and see them as 
the same thing. When we show our volunteers 
those slides with the statistics and data, they 
think, "I cannot do that." We are doing a lot of 
training right now to teach our local folks how 
to do evaluation. It can be as simple as a pretest 
and posttest or can involve more statistical data, 
but it still scares them. They think they just can- 
not do it. They do not have the staff time to do a 
lot of this, especially if they have only a .01 full- 
time equivalent who is assigned to work on this. 

The major question is how to teach community 
volunteers to do evaluation without an infusion 
of staff and money and how to do it in a cultur- 
ally sensitive manner. There are few data on the 
cultural aspects of prevention. The risk factors 
may be the same, but prevention programs must 
be implemented differently. We are learning that 
in Oregon in our work with Native American, 
African- American, and Asian communities. It is 
difficult to develop such programs and track them 
without more resources and dollars. 



130 National Conference on Drug Abuse Prevention Research 



There are multiple levels of evaluation. One is 
to look at drug use; another is to look at what is 
targeted and whether there is progress in achiev- 
ing risk factor changes. 

Work Group on Prevention 
Through the Schools 

Panel: 

Gilbert J. Botvin 

Cornell University Medical College, NY 

Jodi Haupt 

National Prevention Network and Missouri 

Division of Alcohol and Drug Abuse 

W. Cecil Short 

National Association of Secondary School 

Principals, Riverdale, MD 

Moderator: 

James Colliver 

National Institute on Drug Abuse 

James Colliver 

The purpose of this work group is to discuss the 
implementation and application of school-based 
prevention programs, identify issues, develop 
recommendations regarding prevention research 
and practice, and make recommendations for new 
materials and services. 

The panel leading the discussion includes Dr. 
Gilbert Botvin, a prevention research scientist, 
Ms. Jodi Haupt, a State representative of the 
National Prevention Network, and Mr. Cecil 
Short, a community leader. Dr. Botvin is the di- 
rector of the Institute for Prevention Research at 
Cornell University's Medical Center in New York 
City. He has many years of experience as a pre- 
vention researcher and he is the developer of the 
Life Skills Training program, a school-based 
approach to drug use prevention. Our commu- 
nity leader, Cecil Short, is president-elect of the 
National Association of Secondary School Prin- 
cipals and a middle school principal in Riverdale, 
MD. Jodi Haupt, our National Prevention Net- 
work representative, is a program coordinator at 
the Missouri Division of Alcohol and Drug 
Abuse. Ms. Haupt and Mr. Short each will 
have 5 minutes to respond to Dr. Botvin's speech 
from this morning; Dr. Botvin will then take 
5 minutes to comment on the issues raised by 



the other panelists and clarify any points from 
his presentation. 

Jodi Haupt 

I appreciate the coordination of all the present- 
ers and their consistent message. It appears they 
took advantage of a "teachable moment" to show 
us true modeling of prevention by presenting a 
consistent message. The presenters touched on a 
number of common [themes]. The key points, 
especially from my perspective with a single 
State agency, include the following: (1) preven- 
tion has to be about what works; we need to re- 
place ideology with science; (2) strategies must 
be long term, with booster sessions in following 
years; (3) there must be consistent messages be- 
ginning early with young children; (4) preven- 
tion must be culturally specific and must target 
all forms of drug abuse, not just single out one 
or two; (5) there is a need for parental involve- 
ment; (6) the problem is complex and its solu- 
tion means a coming together of the biological 
and behavioral sciences; (7) tailoring of the pro- 
grams is critical — something that is key to Mis- 
souri now. 

In Missouri we often miss the boat by not put- 
ting the cards on the table and telling kids how 
they are influenced by their peers and the media. 
In my State of Missouri, Anheuser Busch repre- 
sents a lot of liquor industry campaigning. 

In regard to Dr. Botvin's presentation, I was im- 
pressed with the 40- to 75-percent initial reduc- 
tion, the 6-year duration of results, and the use 
of booster sessions, which is something we have 
not done much with in our State. I will talk to 
the Missouri Department of Elementary and Sec- 
ondary Education about the booster idea. 

At some point I would like to address some pro- 
gramming specifics, that is, what might be con- 
tained in the teaching techniques with regard to 
instruction and reinforcement. Does that imply 
a consistent message — maybe in other parts of 
the school setting, in other curriculums, in the 
math classes, in science — or is it something en- 
tirely different? 

I also was impressed with the discussion about 
barriers because sometimes we do not think about 
those, particularly barriers of lack of training, 
limited resources, and low teacher morale. With 



Concurrent Sessions 131 



regard to the theme of starting prevention with 
younger children, I would also be interested in 
knowing whether this program has been repli- 
cated with children before they reach seventh 
grade. 

In the area of additional resources, I would like 
to know more about the issue of parental involve- 
ment. In Missouri, many adolescents in treatment 
programs have a parent who taught them drug 
use in the home. This is further exacerbated by 
peers, the media, and other influences that teach 
that behavior. There is real significance in learn- 
ing drug-use behavior at home, and I wonder 
whether something might be done in that area 
with additional resources. 

I am excited about going back to Missouri and 
working with other organizations that we should 
have been working with all along. We address 
the community-based perspective, of which 
school is a big part, but we have been remiss at 
not integrating and making it a comprehensive 
approach with our education department. This 
as an opportunity to talk to our schools and our 
departments within State government. 

Cecil Short 

I have been a practicing administrator for more 
than 27 years and have an appreciation for this 
type of program, which heightens the awareness 
of school administrators. I represent an organi- 
zation of more than 42,000 school administra- 
tors. My comments will be a commendation to 
Dr. Botvin for sharing his thoughts. I would also 
like to issue some challenges. 

This is a drug culture. The term "the war on 
drugs," should probably be changed because the 
problem of drug use involves the human dy- 
namic, not necessarily the military dynamic or 
related metaphors. On a national basis, I would 
challenge distinguished lecturers like Dr. Botvin 
to continue to espouse the message from the drug 
culture perspective, using the human dynamic. 

Especially noteworthy in this discussion are drug 
resistance skills, because in my opinion, that is 
what it is all about from the school's perspec- 
tive. I have not heard a presenter address drug 
resistance skills. At the secondary school level, 
we hear about students who are part of the drug 



culture at the elementary school level. That is 
frightening. 

I challenge the speakers to involve other stake- 
holders in this drug culture. The primary stake- 
holder, as I heard this morning, centered around 
school personnel, but today we are dealing with 
young parents who cannot demonstrate the cop- 
ing skills to meet the needs of their children, 
which is a different phenomenon. After having 
served as a school administrator for 27 years, I 
have come from a dynamic of disciplining chil- 
dren by just clearing my throat to having to send 
for a security guard. "Security guard" was not 
even in the vocabulary of the school adminis- 
trator 10 years ago. There is a different culture 
today. 

I like the idea of social influences. The national 
slogan "Just Say No" will not do it for people 
who see a profit motive in the drug culture, and 
it will not work for a kid who makes more money 
in 1 week than the school principal. We have to 
do more than that. There has to be, in my judg- 
ment, treatment or exposure from a cultural 
health perspective. 

I think we need to do more instruction in peer 
group types of environments, because the peer 
group does have a tremendous influence. Bring- 
ing youngsters into a classroom or an auditorium 
for a once-a-year program — and I have a great 
program, the DARE program — may not be mak- 
ing an impact. 

I like the idea of peers. We need to find the peers 
of these youngsters and speak to them. More in- 
formation should be given to the school person- 
nel about drug resistance skills, comprehensive 
life skills, and the social influences approaches. 

In closing, we have to be careful about the type 
of program approach that has a short shelf life. 
Every year there is a new paradigm shift and a 
new "alphabet soup." We need to have a pro- 
gram, run it from A to Z, and stay with it. If it is 
important, it ought to become a national move- 
ment, and everybody ought to line up behind it 
and march to the same drummer. We are in the 
parade, but some of us are marching to the beat 
of a different drummer. 



132 National Conference on Drug Abuse Prevention Research 



Gilbert Botvin 

Let me respond in the opposite order and pick 
up on some of the themes that Mr. Short men- 
tioned, especially the last one, which resonated 
with me and which has concerned me for a long 
time. I said today and have said, humorously at 
times, in talking with various folks, that we have 
a real problem as a country. We have a national 
case of ADD, or attention deficit disorder. To 
some extent, the media may be more responsible 
than anyone else. Maybe the media, and not the 
public, are the ones with ADD. 

Clearly, someone has difficulty paying attention 
to problems for a reasonable period of time. No 
sooner do we begin to work on solving one prob- 
lem like drug abuse, teen pregnancy, or AIDS, 
than we are off to working on another problem. 
Almost every year there is a problem of the year. 
I think we need to get away from that mentality. 
We are going to make progress only if we con- 
sistently focus on these problems. We may need 
to focus simultaneously on many of these im- 
portant public health problems, but clearly we 
have to set a national priority. We have to have 
an agenda that allows us to work on these prob- 
lems until we can make some progress and not 
just bounce from one thing to another. 

It is clearly important that we refocus the way in 
which we approach the problem of drug abuse 
prevention. This war on drugs metaphor has been 
an unfortunate one. I agree that it does not ad- 
equately capture the social aspects and the di- 
mension of the problem. 

What we are talking about is trying to develop 
interventions that deal with the whole kid, inter- 
ventions that do not just teach kids to say "no" 
or beat them over the head with facts, but inter- 
ventions that deal with real-life concerns and give 
kids the skills they need to succeed in a frequently 
hostile environment, whether it is at home, at 
school, or traveling to school. Unfortunately, 
many of our kids live in a hostile world. We need 
to give kids the skills to cope with that world 
and to succeed to the greatest extent possible. 
So we need to think about this in a different way. 
Hopefully, the kinds of messages coming out of 
this conference today will help us to see things 
in a somewhat different way. 



Involving the various stakeholders is a real chal- 
lenge to all of us who do research. We have one 
set of skills. We know how to do research. We 
know how to organize and conduct studies. We 
know how to distill the literature, develop theo- 
retical models and intervention programs, con- 
duct evaluations, and interpret the results. We 
even know how to write articles for scientific 
journals. But what we do not know how to do is 
talk about what we do in a way that is intelli- 
gible to people who have to go out and make a 
difference. We sit around at conferences and talk 
to one another and get excited about high P- 
values and fancy multivariate statistics. But we 
are not saying the kinds of things that can make 
a difference in the real world. We have to move 
from our ivory tower situation to the real world 
and to talking with people like many of you here 
today who can make a difference in the real 
world. 

We have talked at this conference about schools, 
but clearly there are other stakeholders and 
gatekeepers. We have formed alliances so we can 
all work together to see that proven prevention 
approaches get more widespread utilization. We 
need to involve not only the schools but also dif- 
ferent groups in the community. 

You are quite right that in many of the inner cit- 
ies and in some rural populations parents are only 
a little bit older than the kids themselves. They 
do not have the skills. They may have problems 
of drug abuse. They may have a whole array of 
deficiencies with respect to many of the personal 
and social skills that we think are important. In 
those instances, we need to do more than just 
provide an intervention for the kids. We have to 
figure out ways of involving the family, getting 
them to have a stake in this, and helping them 
with their problems. There are many good 
family-level interventions that are currently 
being tested that can help to do that. 

Our work only addresses kids in school, although 
we have made some efforts to involve the fam- 
ily and work with parents through videos and 
homework assignments. However, it is difficult 
in many situations to do a whole lot. If you come 
from a normal family, that is fine. If you come 
from a family like the one on television in "Third 



Concurrent Sessions 133 



Rock From the Sun," which is a little bit wacky, 
that is something else. If you come from a fam- 
ily that is totally dysfunctional, where the par- 
ents are using drugs, that is a situation that almost 
seems entirely hopeless and clearly is difficult 
for us. 

Even at our best, given the fancy statistics or the 
dramatic results that some programs produce, if 
drug use is cut in half, that is great, and we should 
all be excited about that. But that still leaves half 
the kids who are using drugs. Some kids may 
come from dysfunctional families or from fami- 
lies where one or both parents are using drugs. 
We may have a very hard time reaching those 
kids. 

We clearly do not have the kinds of interven- 
tions that can make an impact on hardcore, high- 
risk kids; we need to do more work in those areas. 
We need to move beyond just saying "no"; that 
is not enough. That is one of the main messages 
I hope that you can take away from my talk this 
morning. You need to do more to reach out and 
work with the whole kid, because if we do not 
deal with their whole lives, if we do not give 
them the skills to cope with life and to succeed 
in the worlds in which they move, we are not 
going to have an impact on this great national 
tragedy that we see before us. I certainly agree 
with the importance of focusing on peer groups. 
In a lot of the work that we do, we attempt to 
work with kids within a group setting, utilizing 
peers and taking advantage of issues that may 
relate to peer socialization. 

In response to some of the points raised by Ms. 
Haupt, it is important that we disseminate infor- 
mation about what works and the content of our 
prevention programs as well as about the way in 
which these programs can be implemented. There 
are various teaching techniques that can be used 
in prevention programs, and some of these tech- 
niques may be less effective than others. In our 
own work, building on work in some of the clini- 
cal areas, we have found that there are certain 
approaches to skills training and certain tech- 
niques that have been found to be helpful in past 
research. 



We have imported those approaches that come 
from a clinical setting and have used them in what 
some people have referred to as this "psy- 
choeducational program." For example, we are 
teaching kids skills for dealing with stress and 
anxiety and managing dysphoric feelings of de- 
pression. We are trying to teach these skills 
proactively so that kids have the ability to man- 
age their own emotions, their own feelings, and 
the various issues that confront them. But we 
have to do that in a way that is going to be effec- 
tive using the right techniques. 

It is important to have reinforcement in all these 
programs; that is part of the importance of a 
booster intervention. However, in the kind of 
work that we have done, we have not had mul- 
tiple levels or multiple channels of communica- 
tion that would help us provide reinforcement of 
these various messages because of the nature of 
our intervention. Multichannel, multicomponent 
interventions are needed to provide various ways 
of reaching not only the children, through the 
schools, media, schoolwide support activities, 
and after-school programs, but also the parents — 
reach the kids by reaching the parents. 

I wish I had an answer to your question of how 
we should deal with the many barriers. I do not 
have a great idea of what we can do to solve prob- 
lems of inadequate resources or low teacher 
morale. I know what would help to change that, 
but I think you are talking about systemwide 
changes and no small amount of money that 
would be required to do that. You need to change 
the school environment, make it more user- 
friendly, make it a better place for kids, make it 
a better place at the same time for teachers, as 
well, so that they feel more empowered and en- 
thusiastic about their work. 

Many of the teachers in New York City who are 
hard-working, dedicated teachers have a hard 
time when there is no place for them or their stu- 
dents to sit. Those deplorable conditions have to 
change. It is difficult to learn and to conduct pre- 
vention programs under those conditions. 



134 National Conference on Drug Abuse Prevention Research 



These barriers will take resources beyond those 
that are available, but there are things we can do 
to enhance the fidelity of implementation. One 
is to be careful in selecting teachers to imple- 
ment programs like this. You need people who 
are enthusiastic, who want to be involved, and 
who do not have to have their arm twisted by the 
principal or the superintendent to do this. 

A few years ago at the request of a school super- 
intendent, I was giving a presentation to his prin- 
cipals about a program that we were about to 
conduct under some Federal funding. They were 
enthusiastic. Unfortunately, as it turned out, he 
was super-enthusiastic, and the more enthusias- 
tic he became, the less enthusiastic they became. 
It turned out that there had been a history of 
"labor/management difficulties" — bad commu- 
nication, bad faith, and other problems. So this 
well-intended superintendent, who up until that 
point I had been thrilled with because he loved 
what we wanted to do and was very enthusias- 
tic, did something that turned out to be irrepa- 
rable and unforgivable. He essentially mandated 
the program for everybody. That became a kiss 
of death for us. In most situations, you cannot 
mandate programs and in this case, his enthusi- 
asm and zealousness, although wonderful, turned 
out to be a problem for us. 

You have to bring everybody along, and people 
have to have a sense of ownership about these 
programs if they are going to be involved and 
excited. You should select teachers who want to 
be involved, who do it voluntarily, who have 
good teaching skills, and who have good rap- 
port with kids. Ideally, you want to get teachers 
who have high credibility with kids, who are even 
charismatic. They are great teachers, and they 
are going to do a great job in implementing the 
prevention program, even if they do not have any 
background in drug abuse prevention. You just 
need good people with good hearts who are com- 
mitted. That is critically important. 

It is also important to train teachers properly so 
they know what they are doing and why they are 
doing it and so they have a sense of hope and 
optimism. After doing this for many years, 
we are able to show teachers that this kind of 



program will make a difference if it is imple- 
mented properly. We give them data so they be- 
lieve this can make a difference if they invest 
time and effort. 

Teachers need training skills and opportunities 
to practice them in a workshop. Ideally, it is im- 
portant to train a minimal number of people from 
the school district so that "lone rangers" are not 
the only ones conducting prevention programs. 
Training, selection, and ongoing support are criti- 
cal components in dealing with the implementa- 
tion fidelity problem. 

The age of intervention is important. Many re- 
searchers believe that prevention should start as 
early as possible. In testing these programs, how- 
ever, it is essential to start with an age group that 
can be followed within the confines of available 
funding and at a time when enough of them are 
beginning to engage in substance abuse or other 
behavior that can be evaluated and that results 
in reasonable and legitimate statistical compari- 
sons. To start too early in a research study that 
may span 3, 4, or 5 years makes it impossible to 
do an evaluation. Therefore, work should be done 
with older populations. For many reasons, the 
middle or junior high school age group is impor- 
tant. It is a critical transition point and a critical 
risk period. For those reasons, this age group 
warrants our attention. It also is a time when the 
onset of drug use begins to rise more steeply. It 
is possible to demonstrate differences between 
treatment and control groups because the base 
drug use rates are sufficiently high in the sev- 
enth, eighth, and ninth grades. 

Parent involvement is critically important. Al- 
though school-based intervention is the primary 
"workhorse," the centerpiece of most prevention 
efforts, the family must be involved. Although it 
is often difficult to involve busy parents or those 
with their own problems, we have to reach out. 
We need to develop more effective ways of reach- 
ing parents so that we have more comprehen- 
sive, multicomponent, multichanneled in- 
terventions. Only then can we have the kind of 
impact that we must have if we are going to pre- 
vent what is shaping up to be a major epidemic. 



Concurrent Sessions 135 



Work Group on Prevention 
Through the Community 

Panel: 

Mary Ann Pentz 

University of Southern California 

Biddy Bostic 

National Prevention Network, West Virginia 

Division on Alcoholism and Drug Abuse 

Lynn Evans 

National Prevention Network, West Virginia 

Division on Alcoholism and Drug Abuse 

Phil Salzman 

Community Anti-Drug Coalitions 

of America 

Moderator: 

Susan L. David 

National Institute on Drug Abuse 

Susan David 

Our panel members are Biddy Bostic and Lynn 
Evans from the National Prevention Network and 
the West Virginia Division on Alcoholism and 
Drug Abuse, and Phil Saltzman, who is from a 
community coalition in Boston. Dr. Mary Ann 
Pentz will respond to the panel and clarify some 
areas. 

Biddy Bostic 

I am the acting prevention coordinator for the 
West Virginia Division on Alcoholism and Drug 
Abuse, and for the past 10 years, I have been a 
volunteer coordinator for a grassroots, compre- 
hensive community-based prevention program 
in South Charleston. I will talk about commu- 
nity issues, and Lynn will talk about the State 
aspects. 

I concur with what has been said about the myth 
that you can "build it and they will come." They 
will not come. But if you let them build it them- 
selves and help them build it, then it belongs to 
the community, and they will come. When mem- 
bers of the community have a vested interest in 
a program, it is theirs. 

A program must be comprehensive in scope with 
a strong no-drug-use message. It must be both 
community-based and school-focused because 



that is where the kids are. A program must be 
multifaceted, and the methodologies have to link. 
A program must also support a social develop- 
ment strategy to give people opportunities, skills, 
and the recognition they need. 

The one area I cannot emphasize enough is train- 
ing, because with training, the community be- 
comes its own expert. It is wonderful to hear 
about all of the research and all of the money 
that is being spent. But for a grassroots commu- 
nity that has little money, you train the folks to 
do the training, which makes it so much easier. 

In Appalachia, sometimes it is not easy for out- 
siders to come in and do training. A strong com- 
munity program must have one particular 
component — community mobilization. Commu- 
nity members need to know why they need to 
mobilize, and a needs assessment must be done 
so that they can figure out the problems. 

I would also like to mention the importance of 
peer programs, parenting programs, and the 
DARE program, which is wonderful, especially 
when used in collaboration with other programs. 
I cannot speak highly enough for peer education. 
When you train a kid to go in and train, you are 
not only training that kid, you are training his or 
her children and their children's children. You 
begin to change norms, including individual, 
school, and community norms. Not only do you 
want input from youth, but also you want their 
empowerment. 

A program should cover the lifespan, including 
preschools, primary schools, and secondary 
schools; the rest will follow. It also should be 
school-curriculum-based with outside resource 
programs — a collaborative effort. It has to be 
multicultural and multigenerational, with an 
evaluation that is easy to conduct. Volunteers 
want to work with the kids; they do not want to 
spend most of their time doing paperwork. 

A program has to be interactive. Once commu- 
nity members are trained, let them adapt the pro- 
gram to their needs and let them be creative. It is 
their program, not yours. Researchers/trainers 
empower the community to empower itself be- 
cause that is what changes the norms. Preven- 
tion is a forever-and-ever reality. 



136 National Conference on Drug Abuse Prevention Research 



Lynn Evans 

I am excited about Dr. Pentz's research, because 
her work bears out exactly what we have seen in 
West Virginia. Although there are many commu- 
nity programs throughout West Virginia, we have 
been working toward a comprehensive approach 
for about 12 years, long before "comprehensive 
program" was a buzzword. Our findings were 
exactly like those of Dr. Pentz, who did the re- 
search and put it down on paper for us. We have 
not had the money to do that up to this point. 

We also found that although there are many pro- 
grams out there, we have to work with commu- 
nities to create a comprehensive prevention 
strategy; otherwise, it does not work. If we em- 
power the communities, they are willing to do 
it themselves. We do not need to do it for 
them. They will do the programs, and they will 
do the prevention as long as we give them the 
guidelines. 

We can use the research we have been given to- 
day to go back to the communities that need some 
concrete evidence that what we have been tell- 
ing is them is now based in fact. We have been 
telling them, because we knew it from our gut, 
but they needed something concrete. 

From a State perspective, I am pleased that there 
are some long-term studies that are now coming 
to fruition and that we can use them to look at 
what are we going to do in the next 6 years and 
how we are going to make it comprehensive and 
longitudinal. 

Phil Salzman 

My experience at the community level — 
20 years of public school work and 15 years of 
community-based prevention work — has taught 
me that we have to start with the data then trans- 
late the data into a framework that average people 
understand. When we talk about protective fac- 
tors, we have to use the words that people who 
care about people use. 

The data are the data, and they are framed in a 
methodology and in a language that is appropri- 
ate. It is critical that the program start from that 
base. Then we need to translate the data, so that 
as we invite people to participate in health and 
wellness promotion, they feel that we are meet- 
ing them on common ground and that they have 



the capacity to participate. They have a core set 
of assets and resources that we often call con- 
ventional wisdom — I like to call it the things my 
grandmother knew. 

That does not mean they have to learn a new tech- 
nology or that we are not reinventing the human 
dimension and inviting them to participate in a 
new human experience. Part of what we are do- 
ing is inviting them into something. We have to 
fund and pull together alienated institutions 
within our community. 

We need to have those kinds of discussions with 
people whose frame of reference is a research 
base. When we talk about a need for community 
systems to interface and be multicomponent and 
collaborative, we have to acknowledge that we 
have abdicated a certain level of responsibility 
within our communities to people who get paid 
to provide that. We have professional people who 
are paid to care; we used to have neighbors who 
cared. 

Part of what I am advocating is the funding of 
community-based research. We need to take a 
look at how multicomponent, intersecting expe- 
riences of participation for youth and adults and 
youth-adult partnerships can remind, redesign, 
and invent a sense of intentional social purposes. 
It is important that intentional social purposes 
get constructed into a belief/vision system that 
is community-based and that explains to a de- 
veloping person what it means to be a normal 
member of that community. 

That community may be defined as a neighbor- 
hood, public housing building, or other group- 
ing. In my experience, the most powerful thing 
that people, particularly youth, respond to is that 
they want to be considered normal. If they are 
growing up in an environment where the condi- 
tions send a message to them that it is accept- 
able to take risks, to use and abuse substances, 
to become desensitized to violence within the 
home and the neighborhood, and if that is what 
normal is, there is a likelihood that they will par- 
ticipate in those activities. 

We also have to acknowledge as communities 
that addiction and substance abuse exist, and their 
total elimination may not be a realistic goal. 
Many community coalitions think they have 
failed if they have not eliminated substance abuse 



Concurrent Sessions 137 



or chemical dependency, despite making progress 
against these problems. 

On a public awareness level, we have to acknowl- 
edge what addiction is, what substance abuse 
intervention is, what substance abuse prevention 
is, and how we can craft a community with mul- 
tiple opportunities to promote health and 
wellness at different stages of development. 
Sometimes, relapse prevention is primary pre- 
vention for the child of an addict. 

Policy is important. I remember clearly a time 
when we used to throw all of our garbage out the 
car window because that was normal, it was not 
against the law, and it was public policy. We did 
not have an environmental movement when I was 
growing up. The combination of public policy, 
public information, social change, and awareness 
changed that behavior and created a new set of 
attitudes about the environment and the commu- 
nity we live in. 

Much attention should be placed on where the 
change agent and the change dynamic begin. The 
approach must be multifaceted from the behav- 
ioral, public policy, and community development 
points of view. We need research into how those 
intersecting, layering initiatives intersect into the 
daily life and perception of ordinary people and 
how that creates a sense of change. 

Mary Ann Pentz 

I will start with the policy issue. I cannot say for 
sure, but in light of the results we have seen so 
far — some new papers are coming out in Janu- 
ary 1997 — communities can get faster, better, 
more supportive policy change if they implement 
other pieces of programs first, with those pro- 
grams in a community focused on building up 
an antiuse norm. That is, if you do it program- 
matically first, and you get children and their 
parents to be aware of that antiuse norm in a sup- 
portive way, they are much more likely to sup- 
port policies and policy changes in schools and 
communities. This is in preference to the other 
way, which is more punitive, in which a policy 
is enacted because we have such a bad drug use 
problem, which causes problems and requires 
enforcement. 

I want to deal with barriers first. One barrier is 
present when a coalition starts out as a separate 



entity in a community. One of the best ways to 
get everybody involved in singing the same mes- 
sage is to get the schools to support your effort. 

I will give you a "bad case" example of a small 
city in southern California when I first moved 
there. I was asked by a prominent parents' group 
to monitor what they were doing. They were 
aggressive, and they did not like the school prin- 
cipal. They started their own Parents Who Care 
group and were not going to work with the 
school. It fell flat on its face, and when it got bad 
press, they could not get the support of the school. 

When community leaders are involved in any 
kind of community organization or coalition, they 
are usually people who volunteer for a variety 
of things. They are good people, and we have to 
make sure that we do not burn them out. One of 
the ways we have found to prevent burnout is to 
ask people to make a commitment for no longer 
than 2V2 years and to build into the last half-year 
another person they nominate to take their place. 
If they choose or really push to stay on, that is 
fine, but they need to see a limit to their commit- 
ment in a positive way and build in somebody 
else to take their place. Also, you have to expect 
that coalitions evolve over time. 

In Kansas City the coalition effort was the Kan- 
sas City Drug Abuse Task Force, a political en- 
tity that involved the district attorney for the 
whole midwestern part of the United States, the 
mayor of Kansas City, and several other people. 
They had a definite timeline — for political rea- 
sons — to finish their objectives at the commu- 
nity level by 1991, which was also the end of 
our grant period. When they determined they had 
completed their objectives, they disbanded the 
group. 

It is okay for that to happen, but another pos- 
sible model is for people to meet after 2V 2 years 
and acknowledge their efforts to design objec- 
tives that were achievable within 6 months to 
3 years and that would produce demonstrable ef- 
fects. Now that the end of this period has arrived, 
what do we want to do with this? More likely, 
the healthier coalitions will start to change. 

In Indianapolis the Community Action Council 
decided to merge with another group, the Hoo- 
sier Alliance, which was sponsored by the 



138 National Conference on Drug Abuse Prevention Research 



Governor's office and other drug prevention en- 
tities. They have now taken on the mantle of not 
only drug abuse prevention but also some vio- 
lence prevention initiatives. Evolving over time 
is not a bad thing. 

I would also like to talk about the role of the 
researcher. I do not think communities use good 
researchers in the best way they could. A Na- 
tional Institute on Alcohol Abuse and Alcohol- 
ism monograph addresses this topic if you are 
interested. I was trained as a clinical and school 
psychologist, but I was lucky enough in gradu- 
ate school to have one professor who taught an 
invaluable yearlong sequence in organizational 
consultation. It was a University of Texas model, 
and I learned that a good consultant is one who 
listens to the audience. When they tell you what 
they need, you reframe that. Even if you knew 
what you wanted to offer them, you must have a 
meeting point with what they tell you they need. 
Then you say, this is what I hear you saying, and 
this is the way I think I can help you meet your 
needs. Part of the role of a researcher should be 
that of a community consultant, not a paid con- 
sultant, but a consultant in terms of reinterpret- 
ing what a community says it needs in terms of 
what a researcher says. 

The second role of a researcher should be that of 
an information broker, which is particularly im- 
portant if you want to change community policy. 
It takes a long time, up to 3 years we found, to 
change policy, and often what will sway the pow- 
ers that be is how much good information you 
can bring to the table from research about etiol- 
ogy and prevention and costs. A researcher can 
help a community coalition do that. 

The third researcher role is that of an adviser 
when needed. For example, if you have five pos- 
sible school prevention programs and they all 
look fairly similar to your community coalition, 
you can consult a researcher to determine the best 
content to govern decisions about which one to 
use or which pieces of several to use. 

The fourth role, the one typically associated with 
research, is that of evaluator. But a researcher 
does not have to be only an evaluator; there are 
multiple other roles a researcher can play if that 
person has been trained in drug prevention. 



Work Group on Prevention 
Through the Family 

Panel: 

Thomas J. Dishion 

Oregon Social Learning Center, Inc. 

Kathryn M. Akerlund 

National Prevention Network, 

Colorado Alcohol and Drug Abuse Division 

Victoria M. Duran 

The National Parent Teacher Association 

Moderator: 

Rebecca S. Ashery 

National Institute on Drug Abuse 

Rebecca Ashery 

Our panel members are Victoria Duran from 
the National Parent Teacher Association (PTA) 
in Chicago, Kathy Akerlund from the NPN and 
the Colorado Alcohol and Drug Division, and 
Dr. Thomas Dishion from the Oregon Social 
Learning Center. 

Ms. Akerlund and Ms. Duran will comment on 
Dr. Dishion's presentation regarding family pre- 
vention interventions. They will be looking at 
ways of knowledge transfer and considering such 
questions as, How can you take what we have 
learned from science and implement it in your 
programs? What are the barriers? What are the 
cost issues? After their comments, Dr. Dishion 
will clarify any issues they have brought up. 

Victoria Duran 

I am from the National PTA, which is the parent 
organization to PTAs in local school districts. 
There are almost 7 million members nationwide. 
I cannot claim to have direct contact with all of 
them, but we do work directly with our State 
congresses, which provide information and re- 
sources to our local units. 

I was heartened to continually hear throughout 
all of the presentations, and certainly in Dr. 
Dishion's, the vote of confidence and the encour- 
agement that parents definitely need to be in- 
volved. That has been the mission of the PTA 
for 100 years. This is our 100th anniversary 



Concurrent Sessions 139 



year — we were founded in Washington, DC, and 
our membership grew to an all-time high in the 
1970s. Membership has been declining since. 

As many of you know if you are working in the 
community, parent involvement is a struggle. The 
demographics are changing, the family structure 
is changing, and some of the barriers to parents' 
involvement at community centers and at schools 
are becoming greater. At the national level, we 
try to create model programs and initiatives to 
encourage our local units to get involved in ini- 
tiatives like those that have been discussed at this 
conference. 

Parents need to be involved as partners, rather 
than being talked to or preached at. Parents need 
to be involved as equal partners in many of the 
different initiatives that happen at the commu- 
nity and school levels. We need to be aware of a 
parent's number one concern. National surveys 
of our membership show that substance abuse is 
parents' number one concern. 

Kathryn Akerlund 

We have been blaming parents for everything for 
a long time, and we have done little to help them. 
We have not done prevention at the universal 
level with parents, which points up one of the 
barriers: When, where, and how are we going to 
offer all of these programs to parents? I suggest 
that we start thinking about whether we do it in 
the workplace or when parents are at school. 
However we need to get them more involved, 
and we are going to have to take it to them rather 
than build it and expect them to come to us. 

As panel participants, we were asked to think 
about whether the findings fit our perceptions of 
the nature of the problem. The after-school prob- 
lem is not only substance abuse but also teen 
pregnancy. Most teens get pregnant after school 
between 4 p.m. and 6 p.m. If we can solve some 
of that after-school problem for parents, we can 
also solve a lot of the other problems that are 
related to substance abuse. 

I think we can do more at the State level. For 
example, we can get all of the State agencies that 
are involved in prevention to focus on parenting 
programs. We need to be using all types of pro- 
grams because one size does not fit all. For ex- 
ample, where family preservation might work 



with one family, another type of program will 
work with another family. 

The barriers are incredible. Although there are 
some great programs out there, it may cost $300 
to $400 to get parents involved. When parents 
must decide whether to spend that money on 
clothes for the kids or spend it on going to a class, 
they are going to choose clothes for the kids. We 
need to make things more workable for them. 

Therefore, we need to get the rest of the commu- 
nity involved. One way is getting our "critter 
clubs" — the Elks, the Lions — involved. They are 
in all of our communities, and they are parents 
who want healthy communities. Often they are 
just looking for a good cause to get involved with. 
In Colorado one of the clubs came to us and said 
they had heard what we had been doing about 
fetal alcohol syndrome and that we had a 5- 
minute video. They wanted to put the video into 
every doctor's office in our county. They paid 
for the videos and got them into every doctor's 
office. 

NIDA should take what you are doing and get it 
out all over the country. I think that is one of the 
funder's responsibilities, to pass on the results 
of grant research in lay language so people can 
use it. 

Thomas Dishion 

I want to talk about the barriers. I mentioned the 
need for a menu of services to offer parents. We 
have to get away from the one-program-only 
model. Even in a community where the one pro- 
gram seems to be the best fit for many parents, 
parents tend to respond better to a menu of serv- 
ices. We also need to get away from assumptions 
about how much we need to intervene. 

For example, when working with parents in 
groups, we looked at those families that made 
enormous changes and when they made them. 
In a psychoeducational model, you would ex- 
pect that the more skills the parents learn, the 
more change would accumulate and that the most 
dramatic change would happen at the last ses- 
sion. However, that was not the case. The par- 
ents who changed dramatically did so after only 
3 of the 12 sessions and maintained that change. 
A sudden shift happened. 



140 National Conference on Drug Abuse Prevention Research 



Perhaps we should look at a few more assump- 
tions in terms of how much parents need. When 
we approach a single parent who is working full 
time and ask that person to be involved in a 16- 
week group for 2 hours a night, it is a miracle to 
me that he or she shows up. It is a huge commit- 
ment. If they do not need the full 16 weeks or if 
we are overteaching, then we are not doing them 
a service. I am starting to think that might be 
true. 

If we organize groups around salient issues that 
are happening right then, parents come in. If it is 
child-centered — for example, on the school per- 
formance of kids — suddenly attendance goes up 
from 20 to 85 percent. Participation depends on 



how we present what we are doing. If we call it a 
parent training program, the numbers go down. 
If we describe it as a night focused on concerns 
about what kids are doing after school, the num- 
bers go up. When the focus goes from the parent 
to the kids, all of a sudden parents start showing 
up. 

There are many such issues that we need to think 
through. And it is not just the researchers who 
can do that best; it is kind of a partnership. It is 
what people have called service delivery re- 
search, which is critical at this point. The focus 
on parents is important. There is much work 
to be done on exactly how best to deliver those 
services. 



Concurrent Sessions 141 



DAY TWO: PLENARY SESSION 



Introductory Remarks 

Alan I. Leshner, Ph.D. 

Director, National Institute on Drug Abuse 



I have been thinking all morning about how to 
introduce Elaine Johnson to the prevention com- 
munity. The truth is, you don't; you just say, 
"Elaine Johnson is going to be our speaker." 
Everybody knows her. But I do want to say a 
couple of things because I think it is important 
that they be said in this environment. 

We have been talking for the last couple of days 
about the need to integrate research and practice 
in a bidirectional mode where research informs 
practice and practice informs research continu- 
ously. I can think of no one who embodies that 
better than Elaine Johnson. I am particularly 
happy to have Elaine open our second day be- 
cause of her perspective as someone who has 
provided leadership in research, leadership in 
prevention service concept, and leadership in 
prevention service delivery. 

I think most people know Elaine's long and dis- 
tinguished career, but let me remind everybody 



that she comes from NIDA. Elaine Johnson is 
unquestionably one of the most important lead- 
ers in the drug abuse field in this country, having 
served in the Federal Government at the highest 
levels for 20 years. She has been the deputy di- 
rector of NIDA and the director of the Center for 
Substance Abuse Prevention; and don't forget her 
heroic and important national leadership as the 
acting director of SAMHSA. 

We work together a lot, and I like it on multiple 
levels. I like it personally, because everybody in 
the country likes Elaine Johnson. And it has been 
extremely instructive for me. I have learned a 
tremendous amount from Elaine, as all of us 
have, and I have learned a tremendous amount 
from our collaboration and cooperation. 

It is truly a pleasure and an honor for me to in- 
troduce our speaker, Elaine Johnson. 



Day Two: Plenary Session 143 



The Community and Research: 
Working Together for Prevention 

Elaine M. Johnson, Ph.D. 

Director 

Center for Substance Abuse Prevention 4 



I want to commend NIDA for holding this im- 
portant conference. And, to demonstrate how 
important the Center for Substance Abuse Pre- 
vention believes this conference is, we are here 
in full force. There must be 30 members of the 
CS AP staff participating in this conference. We 
are going to gain a lot from it, and I am pleased 
that Alan Leshner and his staff have organized 
such an outstanding event. 

My topic is bringing together science and the 
community and bridging the gap. Most recently 
we have seen a dramatic increase in the public's 
awareness of the problems caused by substance 
abuse and also in society's willingness to act to 
reduce these problems. Now, because of the 
media and the election, private citizens and pub- 
lic officials have become more willing to take 
on prevention and make it a personal and a na- 
tional priority. 

You heard from General McCaffrey, and I am 
sure he mentioned to you that prevention is the 
number one objective in the national drug con- 
trol strategy. We now have a growing body of 
research that gives us important insights about 
the causes of drug problems as well as about ef- 
fective strategies to prevent them. 

Also, we have to keep in mind — as you have 
heard over time from Dr. Leshner and others — 
that we can measure our progress in numbers, 
because fewer Americans use illicit drugs than 
did so more than a decade ago. Looking at the 
area of smoking in the American population, we 
have seen a decrease, as well as for alcohol- 
related traffic accidents. The thing to keep in 
mind is that 78 percent of young people are not 



drug users. That says a lot for our field, whether 
we are prevention research scientists or preven- 
tion practitioners who are on the front line. We 
have made considerable progress. 

This progress is encouraging, but at the same time 
we must be aware that drug use is not a problem 
that ends and that prevention is not a job that 
gets finished. I remember one of our Presidents 
who talked about "turning the corner," but we 
know now that to be a fallacy, because there is a 
need for sustained, vigorous prevention efforts. 
It comes home to us when we look at the latest 
National Household Survey that has shown a 
major increase in marijuana use among those 
between 12 and 17 years of age. So we have to 
bolster our determination to maintain strong pre- 
vention efforts over time, and we must make 
them more efficient and more cost-effective, es- 
pecially in this era of fiscal constraint. 

The knowledge resources of the scientific com- 
munity also must be applied to prevention prac- 
tice. At the same time, scientists must become 
more aware of the crucial knowledge base that 
practitioners have accumulated through years of 
experience, and researchers must be sensitive to 
the practical needs as well as the limitations of 
prevention practice. Therefore, I would like to 
share with you some examples of CSAP's 
efforts to bridge the gap between science and 
research. 

CSAP currently supports three cross-site evalu- 
ations. There is a large community partnership 
program that started in 1990 that has progressed 
the furthest. The community coalitions evalua- 
tion and the high-risk youth grants evaluation 



4 Elaine Johnson is now retired from CSAP. 



Day Two: Plenary Session 145 



began in 1995. The high-risk youth grants in- 
cluded in the evaluation were funded in 1994 and 
1995, so they are just entering their data collec- 
tion phase. This evaluation is a time series, indi- 
vidual measurement design with participating 
and comparison groups of young people. The 
partnership program evaluation is a comparison 
group design measured at two points in time with 
individuals nested within communities. The com- 
munity coalitions evaluation is a time series, 
community indicator design, with individuals 
hospitalized or arrested, but also nested within 
communities. 

The grant programs that we have supported at 
CSAP have encouraged grantees to undertake 
model interventions at each site, depending on 
the needs and the capabilities of the grantees. 
Thus, the partnerships and the coalitions, as well 
as the high-risk youth programs, call for appli- 
cants to design their own prevention programs 
as long as each grant meets certain objectives 
stipulated in the grant announcements. The free- 
dom of choice that went along with the programs 
provided the overall broader goal of empower- 
ing grantees, with the hope that successful ef- 
forts could be sustained beyond the period of 
CSAP's funding. 

We wanted to make a difference in the commu- 
nity, whether it was systems change or individual 
and family change. The result has been different 
interventions within each grantee community. 
However, I want to point out that all communi- 
ties have been recruited with the assumption that 
they will faithfully implement the same interven- 
tion at each site. 

A community trial is run from a central vantage 
point that prescribes the nature of the interven- 
tion to be followed. So the mission of the com- 
munity trial is to examine this common 
intervention in different community settings, and 
the fidelity to the common intervention is more 
important than any concern for community 
empowerment. 

The community partnership evaluation has col- 
lected a broad variety of data, including cross- 
sectional surveys of adults and young people and 
case studies of 24 partnerships over a 5-year 
period. The evaluation is aimed at addressing 
two major questions: Do partnerships lead to a 



reduction of substance abuse in communities? 
How does such a reduction occur? The evalua- 
tion requires a combination of quantitative and 
qualitative data. 

The data collection was completed last June, so 
now we have comparable sets of outcome data 
with two points in time for the 24 partnerships 
and their matched comparison communities. The 
surveys were large-scale efforts with about 300 
adults and 100 youth who were surveyed in each 
of the 48 communities. Unfortunately, it was not 
possible to carry out the youth surveys in all of 
the 48 communities. 

Remembering that data collection just ended in 
June, we must regard any preliminary results as 
just a peek at much more that is to come. Re- 
member that the 24 partnerships were chosen 
randomly from the entire portfolio of grants, and 
we would not expect that every partnership would 
have succeeded. But preliminary results suggest 
that statistically significant lower levels of sub- 
stance abuse were found for 8 of the 24 part- 
nerships, compared with the comparison 
communities, after controlling for the possible 
confounding effects of individuals' demographic 
characteristics, such as age, gender, and race. 

A key part of the continuing analysis will be to 
determine the conditions within these partner- 
ships that might have produced such results, 
along with a similar analysis of the partnerships 
where such results were absent. We also want to 
look at the hindrances to change as well as the 
facilitators of change in those particular commu- 
nities, which could have been from a number of 
different factors, including how the program was 
implemented, the type of program, or economic 
conditions. Therefore, in further analysis we will 
be able to speak to that point as well. 

Among the important prevention activities in- 
stigated by the partnerships, developing and 
implementing local policies may be just as im- 
portant as operating more traditional prevention 
activities, such as after-school programs, work- 
place programs, and alternative programs for 
young people. The evaluation will be exploring 
these and other potential explanations for part- 
nership success or failure in months to come. 



146 National Conference on Drug Abuse Prevention Research 



The community coalitions evaluation has a more 
complicated task than the community partner- 
ship evaluation. CSAP defines coalitions as clus- 
ters of single partnerships, and in turn, clusters 
of single organizations. From a prevention per- 
spective, the coalitions are expected to be more 
far-reaching than the partnerships because coa- 
litions are larger and contain partnerships within 
them. Coalitions cover a larger geographic area 
or target population and can include a wide range 
of prevention and prevention-related initiatives. 
One of CSAP's expectations is that successful 
coalitions will lead to a variety of desirable 
health-related outcomes and will not be limited 
to only reductions in substance abuse. 

All of these complexities create a great challenge 
for the research team that must attempt to de- 
velop causal attributions under more layered 
conditions, especially when looking at a struc- 
ture as complex as the coalitions. The evalua- 
tion design has just been completed, and the data 
collection is now under way. I know that some 
of you in the audience were instrumental in help- 
ing us put together the evaluation of the coali- 
tions and the partnerships, and we certainly are 
appreciative, because it is difficult to develop an 
evaluation design for such a complex, structured 
prevention initiative. The data will be a combi- 
nation of archival data available from national 
sources, State sources, and the coalitions them- 
selves and will include hospital discharge data, 
uniform crime reports, and data from the fatal 
accident reporting system. 

Note that this data collection plan does not in- 
clude the conduct of surveys, such as surveys of 
young people in schools. Many researchers in 
the audience are aware that such surveys have 
become increasingly difficult to implement be- 
cause of restrictions by local school districts and 
are further jeopardized by proposed Federal leg- 
islation. Such restrictions were the reason that 
CSAP could not cover all of the intended com- 
munities in the partnership evaluation. 

At the same time, a benefit of the coalition evalu- 
ation plan is that it can cover a large number of 
coalitions. The plan analysis also will raise again 
the issue of optimal statistical models, because 
the data will have individuals who will be dis- 
charged from hospitals or arrested under 



varying law enforcement conditions nested 
within communities. 

Whatever the model of choice, the analysis will 
likely have similar characteristics. I will walk 
you through a theoretical framework that we have 
used to evaluate Harvest Youth Programs, which 
include programs that were funded in 1994 and 
in 1995. From this large pool, we have selected 
48 grantees, each with an experimental or quasi- 
experimental design. Data [collection] for this 
evaluation began last spring. The evaluation de- 
sign is sensitive to the importance of program 
characteristics for providing a context and mak- 
ing comparisons between program participants 
and between comparison subjects. Also, in terms 
of subject characteristics, the fundamental ques- 
tions posed in this quasi-experimental design 
involve comparisons between the study subjects 
and the comparison group. The framework also 
includes data on exposure of youth in the treat- 
ment group to specific strategies and services, 
and the analysis involves comparison of change 
and attainment of short-term goals. 

In terms of followup, the design includes meas- 
urements of the level of treatment exposure af- 
ter the prevention interventions have taken place. 
In terms of risk and resiliency outcomes, the vari- 
ables represent the more long-term impact of the 
program. 

The high-risk youth evaluation focus is on both 
intermediate outcomes and outcomes related to 
lower prevalence [of drug use] among the groups. 
Data will be collected from a variety of sources, 
including a youth survey. Our basic design ele- 
ments are a multisite, quasi-experimental study 
with comparison groups and an integrated pro- 
cess and outcome approach. This design, like the 
partnership and coalition evaluation, recognizes 
the important role of qualitative findings and in- 
termediate outcome findings in a successful in- 
terpretation of ultimate program outcomes. 

The evaluation encompasses all 48 local pro- 
grams with 24 programs from the 1994 cohort 
and 24 programs from 1995. The design includes 
the use of a standardized instrument and stan- 
dardized data collection through annual site vis- 
its to the participating grantees. It also includes 
longitudinal surveys of 6,000 participating and 



Day Two: Plenary Session 147 



4,000 comparison youth over four points in time: 
baseline at program entry, posttest at program 
exit, 6 months after program exit, and 18 months 
after program exit. 

The core analysis of outcomes will focus on an 
explication of treatment effects on substance 
abuse attitudes and drug use, and the analysis 
will be conducted to assess immediate effects 
detected through analysis of change in substance 
abuse measures between baseline and program 
exit. The analysis will be expanded to also as- 
sess long-term effects detected through an analy- 
sis of change in substance abuse measures, such 
as the change between baseline and 6-month and 
1 8-month followup, that can be attributed to pro- 
gram intervention. This large-scale evaluation 
study for our high-risk youth program is the larg- 
est that we have ever done. 

I have talked about our community partnership 
and coalition programs, and I would now like to 
focus on our most recent program, our preven- 
tion intervention studies. This new study program 
is driven by the need to support diverse studies 
in a variety of communities, both urban and ru- 
ral. This program is neither a demonstration pro- 
gram nor a community trial program. Rather, it 
is an applied prevention study intended to gen- 
erate new knowledge about how to change the 
developmental trajectory of children at risk of 
substance abuse. It is a cooperative, multisite 
approach that is being used to assess the effec- 
tiveness of interventions to change identified 
predictor variables and to synthesize the results 
derived from this effort. 

To ensure success, the initiative also calls for a 
national research coordinating center that will 
have responsibility to provide overall coordina- 
tion and data management of the multisite re- 
search effort, conduct secondary analysis on data 
relating to the common predictor variables, and 
integrate the results across developmental stages. 
Instead of being a comprehensive program, the 
initiative focuses on the ability to develop and 
evaluate culturally and developmentally age- 
appropriate interventions targeting the develop- 
ment of social competence, self-regulation and 
control, school bonding, and parental caregiver 
investment over one of the four identified devel- 
opmental stages. 



We are beginning [to study the] very young with 
this program. High-risk youth programs histori- 
cally have focused on adolescents, and now we 
are looking at preadolescents, starting with 3 to 

5 years, then 6 to 8 years, 9 to 1 1 years, and 12 to 
14 years. In examining the four predictor vari- 
ables listed above throughout four developmen- 
tal stages, the study attempts to address the 
following question: At what developmental stage 
does enhancement of each of the predictor vari- 
ables prove most effective in preventing or re- 
ducing negative behaviors that are predictive of 
substance abuse? 

This, again, is an experimental design, and it is 
required to assess the effectiveness of the inter- 
ventions targeted at the four predictor variables 
for each one of the developmental stages. Each 
of the sites will target one age group. Both pro- 
cess and evaluation data will be collected from 
target and comparison groups over 2 years. The 
analysis of the data will be conducted in the last 

6 months of the grant period. Depending on avail- 
ability of funds, we plan a long-term followup 
study. 

Finally, I wanted to spend just a few moments 
on the two community trial projects that we have 
been supporting with the National Institute on 
Alcohol Abuse and Alcoholism (NIAAA). It cer- 
tainly is another exciting collaboration between 
scientists and prevention practitioners in com- 
munities represented by these two projects. 

The first project, which has just been completed 
and is in its fifth year, was designed to apply the 
best science-based strategies available to reduc- 
ing alcohol-related injuries and fatalities. The 
four strategies with the strongest research evi- 
dence of effectiveness in reducing injuries and 
fatalities were identified: responsible beverage 
service practices, vigorous efforts to prevent 
impaired driving through well-publicized law 
enforcement, a variety of strategies to reduce 
sales of alcohol to minors, and the use of zoning 
ordinances to reduce the density of alcohol out- 
lets. Scientists worked collaboratively with lead- 
ers in each of the three communities to implement 
these strategies. Two of the communities were 
in California, and one was in South Carolina. The 
communities were culturally diverse and had 
about 100,000 residents each. The project was 



148 National Conference on Drug Abuse Prevention Research 



rigorously evaluated, including extensive data 
collection in these subject communities as well 
as the matched comparison communities. The 
grant resources that were expended under the 
community implementation part of the program 
were very modest. These were expensive 
projects, and both NIAAA and CSAP had lim- 
ited funds for implementation. This effort has 
paid off, though, in statistically significant de- 
clines in alcohol-related injuries and deaths in 
those communities. 

Another community trial project is the Commu- 
nities Mobilizing for Change on Alcohol 
(CMCA), which involved seven communities in 
Minnesota and Wisconsin. Community organiz- 
ers worked with citizens of all ages and from all 
sectors of the community to develop strategies 
for healthy and safe communities in which un- 
derage drinking would be less likely to occur. 
Rather than educating youth on how to resist an 
environment that encourages them to drink, com- 
munities actually mobilized for change on alco- 
hol and sought to change those environments 
that encouraged underage drinking and contrib- 
uted to overall alcohol-related health and social 
problems. 

As you know, altering the environment involves 
change in many practices and policies regarding 
alcohol. By changing the environment that makes 
alcohol so readily accessible and glamorous, a 
community can reduce the degree to which young 
people are encouraged and allowed to drink al- 
cohol. Ultimately, then, by addressing consump- 
tion of alcohol among youth, communities not 
only reduce car crashes, violence, and injuries 
and other health problems but also discover and 
develop capacities to address a wide range of 
issues. 

A major effort within CSAP to bridge the gap 
between science and the community is contained 
in our National Center for the Advancement of 
Prevention (NCAP). While all of the efforts be- 
fore us are important, this one is important be- 
cause it is an ongoing effort from which I expect 
the entire field to benefit. About 3 years ago, 
CSAP established the center with the following 
goals: to conceptualize the prevention field in 
ways that will lead to appropriate application of 
scientific knowledge, synthesize scientific 
knowledge so that it can provide clear guidance 



to the prevention field, and customize the infor- 
mation so that it can be easily used by a variety 
of audiences in the States and communities. To 
accomplish these goals, NCAP has established a 
process for involving both the scientific commu- 
nity and practitioners. 

NCAP products are selected on the basis of two 
equally important criteria. First, there must be a 
good, credible body of scientific knowledge, as 
identified by a panel of senior prevention scien- 
tists in the field and from NIAAA and NIDA. 
Second, the potential product must be useful to 
the field, as judged by a panel of field advisers 
drawn from the States and community organiza- 
tions. Products are then developed with careful 
attention to their scientific accuracy. They un- 
dergo the same kind of rigorous peer review that 
would be carried out in a research journal. The 
products are reviewed also by the panel of field 
advisers to ensure that they are clear and appli- 
cable. They are adapted into a variety of formats 
to make them most useful to different audiences. 

The important goal is to get scientific knowledge 
expressed clearly and in ways that can be most 
easily adopted into practice. These products are 
designed to help policymakers and practitioners 
make sound decisions about which substance 
abuse problems to address, which strategies 
to select, and how to implement them most 
effectively. 

NCAP has also hosted lectures and workshops 
by experts, including scientists, policymakers, 
and practitioners on a variety of critical preven- 
tion topics. These lectures have been recorded 
so that a broader audience can have access to 
them, and NCAP is currently developing a se- 
ries of research alerts to bring recent research to 
the attention of practitioners by disseminating 
brief, easy-to-read summaries of key findings. 
In these and other ways, CSAP hopes to facili- 
tate better communication between researchers 
and practitioners and better use of prevention 
resources through the application of important 
scientific findings to prevention practice. 

I think we have made a tremendous investment 
in generating new knowledge about substance 
abuse and ways of preventing it. All of this money 
and effort and commitment has yielded a great 



Day Two: Plenary Session 149 



harvest for us. We now have a better understand- 
ing of substance abuse, its causes, and its cost. 
We have at our disposal an array of policy strat- 
egies that can have a powerful impact on sub- 
stance abuse and [related] problems. We also 
know much more about a variety of prevention 
programs, how well they work, and what makes 
them work best. 

As I pointed out earlier, we still have a way to 
go — NIDA in terms of its scientific work and 
CSAP in generating knowledge. But when you 
think about our field 10 or 15 years ago, we have 
come a long, long way in terms of developing a 
knowledge base. The time has come to make sure 
that this valuable and hard-won knowledge — 



and, believe me, it has been hard-won on a num- 
ber of fronts — is applied in both Federal and State 
legislative policies and funding choices and in 
the prevention efforts of communities across the 
Nation. 

I have heard Alan Leshner say many times that 
it would be great if our policies were based on 
scientific knowledge and not ideology. Maybe 
at some point we can get closer to that ideal. What 
I have attempted to do this morning is show how 
CSAP is trying to make this work, bridging the 
gap between our practice and research. It is a 
challenging test and one that we all need to con- 
tinue to work on together. 



1 50 National Conference on Drug Abuse Prevention Research 



Panel Presentations: Is Your 
Community Ready for Prevention? 



Moderator's Remarks 

Gloria M. Rodriquez, Ph.D. 
Project Manager 
State Needs Assessment Project 
New Jersey Department of Health 

I want to thank NIDA for the opportunity to par- 
ticipate in this conference and to share with you 
some of New Jersey's experiences in keeping 
with the theme of the conference, which is put- 
ting research to work for the community. 

Today we have a wonderful panel composed of 
State and local community leaders who have ex- 
periences in linking research and practice with 
service delivery issues and who are ready to share 
their experiences. 

Yesterday we heard over and over again that there 
are certain questions that the community needs 
to focus on when selecting a particular model 
program. These questions include, Does the pro- 
gram address the needs and problems identified 
by a needs assessment? Is the program ready for 
distribution? Has it demonstrated efficacy and 
effectiveness? What aspects of the program 
would have to be adapted to fit the needs of this 
particular community, such as cultural issues? 

Practitioners want to know how much the pro- 
gram costs. How long must it be administered to 
achieve positive effects? Will training, technical 
assistance, and protocols be available? Are manu- 
als developed that will assist in the implementa- 
tion process? 

Some of those questions were answered yester- 
day, and some of them will be answered today 
by our panel. First, I will talk about New Jersey's 
approach to conducting a statewide needs assess- 
ment study. Next, Mr. William Crimi, executive 



director of the Franklin County Prevention In- 
stitute in Ohio, will share with you that county's 
perspective in undertaking a needs assessment 
project to plan prevention services. Mr. Harry 
Montoya of Hands Across Cultures in New 
Mexico will talk about cross-cultural issues spe- 
cific to Hispanic-Latino populations and how 
these must be integrated into a needs assessment 
process and also into program planning and pro- 
gram implementation. Finally, Mr. Thomas 
Connelly, an educator and implementer of the 
Life Skills Training program in New York, will 
talk about implementing that program in the 
school system. 

Putting research to work for the community is 
the theme for this conference and also the philo- 
sophical approach adopted by the New Jersey 
Prevention Needs Assessment Project. New Jer- 
sey is undergoing a major initiative called Pre- 
vention Unification, which is designed to 
coordinate the needs assessment and planning 
process on a county-by-county basis so they all 
work in unison. Counties were asked by the State 
to submit a single, countywide prevention plan 
based on a risk and protective factor model, in- 
cluding a comprehensive needs assessment and 
measurable outcomes. 

Some of you who are representing State agen- 
cies or who are local county and community plan- 
ners may already be doing this. However, this 
is a major shift in our State. Formerly, New 
Jersey did prevention planning on the basis of 
an intuitive, gut feeling of what types of pro- 
grams were needed and why. Now we are shift- 
ing that focus. We are saying that we are going 
to conduct science-based needs assess- 
ment projects and studies — actually a family of 



Panel Presentations 151 



studies — to determine where the problem is, who 
is having the problem, and the extent of the prob- 
lem, and to guide our planning process. 

As part of the unification process, each county 
is already forming working groups with repre- 
sentatives from the entire community, and we 
have heard how important that task is. The 
working groups include the schools, community 
agencies, businesses, municipal and county gov- 
ernments, faith communities, and others. In that 
way, many community institutions become 
knowledgeable about the community's preven- 
tion needs and how best to meet them as they are 
forming the planning process. 

In the midst of this, CSAP announced a major 
initiative, the CSAP Prevention Needs Assess- 
ment Contracts. We applied and were fortunate 
enough to get one. It is one of the best Federal 
initiatives to help develop the State's infrastruc- 
ture, and for this we thank CSAP and CSAT. 
These contracts have enabled New Jersey to pro- 
duce data-driven planning and resource alloca- 
tion processes that otherwise would not have 
been possible. 

I will briefly describe the different types of stud- 
ies we have been undertaking for the past 3 years, 
as well as our three overriding concerns when 
we decided to undertake these studies: 

• One concern was [assessment of] the gaps in 
services. We looked at what data we already 
had and at what data were missing, and then 
we decided to design a study to get that data. 

• Our second concern was to make sure that 
the data being derived from these studies and 
other kinds of activities being undertaken at 
the State level would also fill the needs of the 
local, county, and municipal planners. We 
asked planners what kind of data they needed 
and in what format and how we could help 
them develop their needs assessment studies. 

• Our final concern was that we needed to come 
up with a formula for the reallocation of pre- 
vention resources based on these data. That 
was pivotal to the whole process. 

With this in mind, we decided to look at seventh 
and eighth graders because we had no data on 
this population. We have protocols for all of the 
surveys I am going to talk about, and we are in 



the process of finalizing the report. If you are 
interested in the particulars of the design and 
some of the results, you can contact me, and I 
will send them to you. 

The mature citizen survey is a unique undertak- 
ing, and we are very proud of it. We decided to 
look at individuals 65 and older to determine the 
prevention needs in this overlooked population. 
We seem to concentrate on kids; however, our 
seniors also have prevention needs that should 
be addressed. 

We also decided to undertake a community leader 
survey, which I will describe later because I 
want to give you more particulars; this survey 
looks at community readiness from a different 
perspective. 

One of the cornerstones of a needs assessment 
project is a social indicator study, which com- 
prises three separate activities that we have been 
undertaking. The social indicator study is a study 
of archival data that we have summarized. 

You often hear that prevention programming 
must match the nature of the problem in the com- 
munity. However, few communities have the 
wherewithal, especially the financial means, to 
conduct a science-based needs assessment study 
that looks at all of the different, complex fac- 
tors. Therefore, when we asked county coordi- 
nators what they would like, they said, " We want 
you to produce something for us that we can 
understand. Don't give us tables because it is 
difficult for us to interpret those data." 

Keeping that in mind, this is exactly what we 
went about doing. We used a factor analysis pro- 
cedure and developed composite risk indices to 
summarize all of the municipal-level data. We 
compiled 50 municipal profiles that looked at risk 
and protective factors in the four domains and in 
the subdomains. We gathered data from the sur- 
veys, from the census, and from other archival 
kinds of data and came up with risk indices and 
risk scores for each city and each county. In this 
way, local planners could easily see where their 
city stood with respect to all the different risk 
domains as opposed to the State or averages. 

Some of our counties look a little bit different 
from some of the cities within counties because 
some of those cities within counties drive the 



152 National Conference on Drug Abuse Prevention Research 



data. For example, Essex County may not look 
as bad on the risk indices, but if you look at the 
city of Newark within Essex County, you will 
see that it is not Essex Fells in Essex County that 
is having the major problems but Newark and 
East Orange in Essex County that are having 
most of the problems. This approach teases out 
the data to the lowest possible level to allow 
county and municipal planners to zero in and 
target prevention programming and different 
kinds of plans and activities where they are 
needed. 

Our chartbook is close to 100 pages, and the raw 
data are included at the end as an appendix. We 
are planning to continuously update the infor- 
mation as the data change. This is an ongoing 
process, not a one-shot deal, and we have made 
a commitment to the county and local planners 
to update this chartbook as new data become 
available so they will always have up-to-date data 
on which they can base their planning. This is 
especially important in conducting outcome 
measures for the prevention activities. Planners 
can look at current baseline measures in all of 
these risk domains and compare them with 
the results after the prevention programming is 
completed. 

State employees should remember that they are 
collecting data not only for their needs but also 
so that they can be used at the local and county 
levels. County, municipal, and other planners 
should make sure that they "reach out and touch" 
the State people and say, "No, what you are pro- 
ducing is not making any sense for us. We need 
this interpreted for us." 

Our community leader survey is a fascinating 
piece. It looks at community cohesion, which is 
a piece of the community readiness approach. 
Without going into the theoretical basis, I want 
to share with you whom we surveyed. We looked 
at major groups — education, law enforcement, 
public health, and local government. We also 
looked at the faith community and business. 
Within each one of those, we looked at two spe- 
cific leaders. 

In the education area, we surveyed superintend- 
ents of schools and presidents of the boards of 
education. In law enforcement, we looked at 
police chiefs and prosecutors. In public health, 



we looked at hospital directors and mental health 
directors. In local government, we looked at 
mayors and public health officers. In the faith 
community, we looked at religious leaders who 
were recognized in the community as participat- 
ing in prevention activities and then at interfaith 
organizational leaders of major interfaith coali- 
tions within those counties. We also looked at 
business, because we felt that business was an 
integral part of this whole prevention activity. 
We looked at the largest employers within that 
county or municipality and at chairs of the cham- 
bers of commerce. 

We asked these individuals about several major 
areas. We wanted to know the priority of sub- 
stance abuse problems in their community, the 
target population that they perceived needed pre- 
vention programs, the efficacy of prevention 
approaches that had been utilized, and the ac- 
cessibility of substances within their counties and 
municipalities. Then we wanted them to judge 
the importance of these factors in the develop- 
ment of prevention activities. 

Armed with objective data from the social indi- 
cator study from our middle school survey, 
we are now able to compare the perception of 
what the problem is versus our objective, data- 
driven analysis of what the problem is within 
municipalities. 

Eighty-five municipalities received a mail sur- 
vey, which resulted in a 5 1 -percent response rate, 
which is pretty good for a mail survey. We did 
cohesion scores to assess what these community 
leaders were thinking about and wanted to do in 
their community, irrespective of what we know 
from the science base — which is what kinds of 
programs fit best for what kinds of problems. If 
you are interested in knowing about this, I will 
send you the protocol, and we can share our fi- 
nal report with you. 

We feel we have a very rational approach. How- 
ever, policy and program implementation does 
not necessarily follow a rational approach, which 
is why we decided to look at cohesion with com- 
munity leaders to try to prevent the disconnect 
between policy and research and program plan- 
ning and research. We also wanted community 
coalitions and partnerships to be aware of what 
they were facing if they tried to implement 



Panel Presentations 153 



programming that was not in concert with what 
community leaders felt their community needed. 

Panel Presentations 

William F. Crimi 

Executive Director 

Franklin County Prevention Institute 

I want to acknowledge three organizations be- 
fore I begin. One of them is the Center for Sub- 
stance Abuse Prevention, which took the 
challenge and the risk of directly funding com- 
munities to create and build comprehensive 
community-based systems of prevention. Join 
Together and the Community Anti-Drug Coali- 
tions of America provided communities with re- 
alistic and practical technical assistance to get 
the job done. So on behalf of many, many com- 
munities, thank you. 

I like the saying that unless we utilize the les- 
sons learned from the past we are destined to 
keep repeating them. Thirty years into the chal- 
lenge of addressing substance abuse problems, 
it sometimes becomes frustrating that we keep 
doing the "same old, same old." 

I represent Franklin County, which includes Co- 
lumbus, OH, and we are fortunate to have re- 
ceived a CS AP Community Partnership Grant. I 
want to talk about the process we went through 
in integrating prevention research into a strate- 
gic planning process. 

Columbus already had a system of prevention. 
The public entity that funds substance abuse and 
mental health programs funded 30 prevention 
programs. When we did our needs assessment, 
we found 40 additional ones. Therefore, we found 
that a lot of activities were going on, but people 
were going off in very different directions. 

Our goal as a community partnership was to help 
all the arrows point in the same direction to 
achieve a larger goal. First, we conducted a needs 
assessment to get a snapshot of what the land- 
scape looked like regarding alcohol and other 
drug problems. We also wanted to measure the 
community's readiness to coalesce around the 
issue of substance abuse prevention. We also 
wanted look at things like funding streams, how 
dollars are allocated, and who is funding pre- 
vention services, and to review the current pro- 
viding systems. 



We then began a process of researching effec- 
tive alcohol, tobacco, and other drug prevention 
model activities and came up with the ones that 
you are all familiar with, most of which came 
out of some of the CSAP literature and other 
popular literature: skills-building, community 
mobilization, alternative activities, advocacy, 
mentoring, and role-modeling. What we learned, 
not surprisingly, is that the community did not 
have a real understanding of prevention and how 
prevention works. 

So the first order of business was to begin a com- 
prehensive community awareness campaign to 
give a clear, concise prevention message to the 
community. That consisted of billboards and 
PSAs on television and radio, a poster campaign, 
and various appearances on TV shows and press 
releases through the media. We wanted to at least 
begin at a level where the community could be- 
gin to conceptualize what prevention was. In our 
community partnership, we initiated the "learn- 
ing laboratory," where partners committed to 
meet on a regular basis for a year to begin the 
transition from activities to thinking more stra- 
tegically about prevention and designing a com- 
prehensive prevention system. 

We wanted to avoid getting involved in the ac- 
tivities trap, that is, doing, doing, doing, and not 
thinking of how multiple activities fit into the 
bigger picture. 

It was a wonderful experience, and some of the 
data that we received from those who went 
through that learning laboratory were beneficial 
because they indicated how the participants saw 
the community partnership and the organizations 
that they represented. Their bottom-line recom- 
mendation was that we needed to develop a strat- 
egy that would be more comprehensive than a 
series of individual programs, but these programs 
would still be part of the overall strategy. 

So we went through a process of getting input 
from the entire community on what kinds of 
things should be included in a comprehensive 
substance abuse strategy. Within the county, 
we conducted over 30 focus groups with all sorts 
of different configurations. The result was the 
draft version of our strategic plan, which we 
called "Promises of a New Day." Our next chal- 
lenge was to begin to develop a framework for 



154 National Conference on Drug Abuse Prevention Research 



directing and evaluating the progress of that strat- 
egy. Our coalition, like many of yours, is made 
up of over 60 organizations, so the challenge was 
to make the tent broad enough so that everyone's 
agenda and mission could fit under it. Our broad- 
based mission was to prevent the harm from sub- 
stance abuse. 

We decided to look at three goals according to 
populations of infants and preschoolers, children, 
adolescents, and adults, because in our county 
we tend to keep data on those groups. Much of 
the data came from Healthy People 2000. We 
wanted to look at health status objectives or those 
desired changes in individual health and well- 
being that could be stated in measurable terms; 
to look at risk-reduction objectives or those de- 
sired changes in individual behavior, perceptions, 
and beliefs stated in measurable terms; and fi- 
nally, the strategy objectives, those programs or 
policies and funding streams, which are also 
stated in measurable terms. This paradigm was 
created by the health department, police depart- 
ment, our local board that funds alcohol and other 
drug and mental health services, drug-free 
schools, and the health coalition in central Ohio. 

We thought that drug education had to be an 
important and viable part of the strategy — by that 
we meant multisession, culturally meaningful, 
and age-appropriate drug education from 
preschool through college. This included neigh- 
borhood-based support, specifically neighbor- 
hood-based community programs that meet the 
needs of kids between 2:30 and 6:30 p.m., a 
period that our data tell us is when kids are most 
vulnerable. 

We are in the process of doing a policy panel on 
youth violence, and we are holding town meet- 
ings throughout the county. It is amazing to me 
that parents keep coming up and testifying that 
the times that they are most concerned about are 
those hours when they are at work and kids are 
out of school, between 2:30 and 6:30 p.m. We 
are happy to see that we are in sync with the com- 
munity on that. 

Community policing was an important part of 
that strategy; enforcement and the community 
should come together as problemsolvers to ad- 
dress community challenges. 



We talked about workplace strategies and com- 
munity involvement, with both adults and youth 
joining together to address neighborhood- 
specific substance abuse prevention efforts and 
ongoing public awareness campaigns. We also 
included two more issues that are not usually 
mentioned in discussions of comprehensive pre- 
vention systems: One is access to treatment, and 
the second is jail-based treatment. As you all 
know, we are not going to build our way out of 
this problem with jails and prisons. We have been 
advocating for local jail-based substance abuse 
prevention treatment and general health educa- 
tion for all those who are incarcerated. 

The challenge is integrating these strategies into 
our framework, and none of this is going to make 
any difference at all unless we believe that those 
policymakers who have the power buy into this 
and sign at the bottom line. So far we have a 
commitment from all of those agency heads who 
agreed to review their funding streams and their 
community plans so that they fit into this para- 
digm. We also established some level of respon- 
sibility and accountability by having the 
partnership sign a memorandum of understand- 
ing that goes beyond 3 years (the political life of 
a policymaker); we are trying to get people to 
sign off on this for the long term. 

The first part is to begin another community wide 
campaign to educate the community about the 
strategic plan. In this first year, we will speak to 
every city council and other units of government 
throughout the county about the strategy. We will 
also talk to school boards — we have 17 districts 
in Franklin County — and then community 
groups, community organizations, and area com- 
missions. We have partners who have signed on 
to become part of a speaker's bureau to help edu- 
cate the community about this strategy. 

Next is the implementation stage. There will 
be an ongoing evaluation after the CSAP grant 
ends that will be revised as necessary as we go 
along. We also think that it is important that there 
be a commitment from the key prevention sys- 
tem heads to work within the framework, espe- 
cially in developing new kinds of funding 
streams. Categorical funding is not the way com- 
munities experience community problems, so we 



Panel Presentations 155 



are trying to get systems to think more like the 
way communities experience problems, which 
is more conjointly with commingling of funds. 

What did we learn in 5 years of becoming a CSAP 
partnership? Just because the funding was for 
5 years, does not mean that in 5 years there will 
be a substantial reduction in substance abuse. We 
found that it took 2 years just to get people on 
board and to understand what we were trying to 
do. Something magical did happen in the third 
year — and I know "magical" is not one of those 
words that evaluators use. But the "lights came 
on" at different times. Suddenly, people were 
"getting" what it means to coalesce around the 
issue, and that was exciting. It is a challenge to 
get people and systems to think strategically be- 
cause our human service, knee-jerk reaction is 
to think, "How?" It is ingrained in us that if there 
is a problem, we are going to have a program 
instead of thinking more in terms of the larger 
picture. 

We also learned something that was reiterated at 
this conference — that you need to say the same 
thing in different ways over and over again. It is 
what I call the "Coca-Cola Syndrome," that is, 
marketing the same product in many different 
forms and ways. 

We also learned that politics can inhibit the pro- 
cess. And I do not mean just capital "P" politics, 
but I mean some of that small "p" politics, too, 
where agency heads and institutional egos get in 
the way of trying to achieve a goal. 

Sometimes systems have a difficult time seeing 
the bigger picture and seeing the interconnect- 
edness of their efforts. Early in the process, we 
thought we needed to help the community make 
sense of this issue so we wanted to address an 
issue that was winnable. We thought that under- 
age access to alcohol was one of those issues 
that could be winnable for our community. We 
started off talking about underage access to al- 
cohol. From there, we held our first policy panel. 
Some legislation is pending, and we are excited 
about many things that have happened as a re- 
sult of the policy panel. 

But in the beginning it was frustrating for people 
to see how their organizations or agencies inter- 
connected around the issue of underage access 
to alcohol. Initially, the partnership said, "We 



need more people at the table to do that." Al- 
though that is true, it can also be a stonewalling 
strategy. At some point, we need to believe that 
the right people are at the table. 

Community partnerships and coalitions some- 
times have difficulty understanding the role they 
can play in creating a power base. But I believe 
there is only one reason to form a coalition, and 
that is to form a power base. If you are not look- 
ing at yourself as a power base, then you become 
program "doers," not overall planners. So get- 
ting our coalition members to see themselves as 
a power base that can effect social change was a 
challenge and is an ongoing process. 

What has happened as a result of all this? We 
have looked at three things in the past 5 years. 
We have about 10 outcomes at this point, but I 
will discuss only 3: underage access to alcohol, 
underage access to tobacco, and the commingling 
of funding streams around prevention. 

The first result was a significant decrease in out- 
lets that sell tobacco to minors. In Ohio, as in 
other States, it is illegal for stores to sell tobacco 
and alcohol to minors, but it is not illegal for 
kids to buy them. In conjunction with the Co- 
lumbus Health Department and the Franklin 
County Board of Health, we did a compliance 
survey and found a significant increase in the 
number of alcohol outlets that check identifica- 
tion to control underage access to alcohol. This 
is a 3-year study. In the first year, only 34 per- 
cent of the stores that we surveyed checked iden- 
tification. The year after this coalition mobilized 
and jumped on the issue, the percentage nearly 
doubled to 61 percent. More and more stores in 
Franklin County are getting the message that they 
have to check the identification of young people. 
We thought this was a significant outcome. 

In terms of tobacco access, because it is not ille- 
gal for kids to attempt to buy cigarettes, we sent 
kids into stores to purchase a pack of cigarettes. 
These kids looked like kids — [obviously] they 
were not 18. We found that 78 percent of the 
stores sold them cigarettes without asking any- 
thing. Then we did an intervention immediately 
afterward, and in 90 days went back. After the 
intervention, the percentage of stores that sold 
cigarettes to the teenagers went down to about 
24 percent. We were really happy with that. 



1 56 National Conference on Drug Abuse Prevention Research 



The other significant thing that happened — and 
this did take 5 years — was the creation of a new 
funding stream among the United Way, a local 
Columbus foundation, and our local Alcohol and 
Drug Addiction Mental Health Board, which put 
together some money to look at substance abuse 
prevention and violence prevention as a com- 
bined issue. This was the first time in our county's 
history that those three agencies came together 
to collaborate around a demonstration project. 
An exciting evaluation component will be 
part of all of this. We are going to do a trilevel 
evaluation: 

• The first level will look at the collaboration 
among the collaborating agencies and ask 
questions such as, "Are there any policy out- 
comes that will result from this collabora- 
tion?" 

• The second level will look at the grantees. 
We want to break away from a tradition that 
says you give grantees money and then you 
see them at the final report. There are 10 
community-based grantees that meet together 
every month in a learning laboratory session 
for 2V 2 hours. The first hour is devoted to help- 
ing them design their own evaluations, and 
the second hour consists of networking and 
peer-to-peer technical assistance. Our premise 
is that by giving more technical assistance, 
we will see a better outcome at the program 
level. This has been an exciting process, es- 
pecially because the grantees were resistant 
to it in the beginning. On their weekly evalu- 
ation sheets, now they are saying things like, 
"We need to do this more often," and "We 
need to be able to get away for 2 days and do 
a big retreat." 

• Finally, the third level of the evaluation will 
look at the impact on the communities from 
those 10 projects. 

We believe that all of these strategies and com- 
munities working together help to operationalize 
what our logo represents, which is that we be- 
come a community that truly addresses substance 
abuse together. 



Harry Montoya 
President and CEO 
Hands Across Cultures 

This NIDA conference has highlighted a will- 
ingness to look at doing things differently and 
merging some of what is happening in the scien- 
tific community with what is happening in com- 
munities around the country. This is a significant 
step for community-minded individuals. 

Fred Garcia, the former deputy at the White 
House's Office of National Drug Control Policy, 
and CSAP have done a good job in keeping pre- 
vention at the forefront. I would also like to ac- 
knowledge the Community Anti-Drug Coalitions 
of America, on whose board I serve, its diverse 
group of individuals, and Jim Copple, who has 
put together a remarkable program and staff. 

I am going to take a step back in terms of every- 
thing that has been said over this past day and a 
half and move from what has been a cerebral 
discussion by bringing a little heart into the dis- 
cussion. In 1977 Seymour Sarason made the 
simple statement that we need to take a look at 
prevention, because it is much more effective 
than our capacity to repair. Short-sightedness 
bordering on blindness to build up the clinical 
endeavor at the expense of prevention is not what 
we should be looking at. We should be looking 
at preventing drug use in our communities. 

We need to frame this discussion of prevention 
in terms of what is happening in our country to- 
day and take into account the diversity that ex- 
ists within our communities and within our 
country. Between 1980 and 1990, the fastest 
growing ethnic groups in this country were His- 
panics, who grew by 53 percent, and Asian and 
Pacific Islanders, who grew by about 108 per- 
cent. The United States now is the fifth largest 
country in the world in which Spanish is spo- 
ken, and it is estimated that by the year 2000, 
more than half of California's population will be 
Spanish-speaking. We must take conscious ac- 
tion in terms of efforts to enact English-only al- 
ternatives that are being presented in certain 
States and communities. 



Panel Presentations 157 



We all approach our work from within a particu- 
lar framework, with a particular world view; 
when we bring that into our work, we are influ- 
encing the culture in which we are working. 
When we look at culture, we explain it in a "folk- 
loric" way or in a way that is "home" or "natu- 
ral." In a culture, we do not have to explain 
anything to anyone about our language, our food, 
our dress, or our dance. All different types of 
culture exist. For example, we have Wall Street 
culture and street culture, and there is a huge dif- 
ference between those two. We need to be aware 
that culture is what we acquire and what becomes 
natural to each of us. It is not transmitted bio- 
logically, but environmentally. Culture plays a 
profound role in who we are; we are programmed 
in our culture. Consequently, prejudices are 
learned, and "cultural dissonance" then becomes 
a clear part of what we need to work on in solv- 
ing problems within our communities. 

Different ethnic groups have contributed to the 
Hispano-Latino culture, including African 
Americans. The rituals of passage, spirit of sur- 
vival, spirituality, and oral tradition of this 
particular culture have influenced what we 
have become and what we see today as the 
Hispano-Latino culture. The indigenous, Native 
American culture has also influenced the 
Hispano-Latino culture in terms of rituals and 
ceremonies and "working" collectively. For ex- 
ample, the concepts of community and collec- 
tive ownership came from indigenous peoples. 
A family was extended. Love of Mother Earth 
and Mother Nature and the different arts are sym- 
bols of the indigenous culture. The resulting 
Spanish culture — the dance, the spirit of adven- 
ture, the language — is important to Hispano- 
Latino people. With the loss of language comes 
a loss of culture. Language is how we express 
ourselves and communicate with others; it is a 
key part of who and what we are as a people. 

In developing assessments, we must be careful 
to develop instruments that are linguistically 
sensitive, particularly if individuals are mono- 
lingual. It is important to know whether they 
come from Central America or South America 
or whether they are Mexican, for example, be- 
cause there are different dialects within differ- 
ent languages and different meanings for 
different words. 



There are some key concepts in working with 
Hispanos-Latinos, especially when working with 
the family. Traditionally, we have had a large, 
extended, independent, agrarian-based system. 
Elderly individuals are venerated. In other cul- 
tures, elderly persons often are not accepted or 
respected for the wisdom they have to give to 
the community. Different models have been de- 
veloped in terms of community, which is the 
extended family beyond bloodlines. Within com- 
munities there is also the extended family that is 
developed by confianze, which means trusting, 
mutual trust, and respect. We must be aware that 
all these things are important in terms of how 
assessment instruments are applied across cul- 
tural lines. 

For Hispanos-Latinos, the term "machismo" rep- 
resents the concept of being the leader, provider, 
and protector, not the common image of being 
drunk all the time — or "macho." We need to take 
a historical look back to see how these terms 
developed and where they came from. 

Language and acculturation have influenced 
changing sex roles within the family. Within 
Hispano-Latino families today, the female has 
become the focal point, the "rooted" base that 
has kept the family culturally grounded. Women 
need to be acknowledged and appreciated for 
what they have done within our families and 
households. 

Spirituality is another key concept in develop- 
ing instruments. Catholicism is the spirituality 
piece of who and what some of us are as a people. 
How do you incorporate spirituality into the text? 
Celebration is an important part of who and what 
we are in terms of our community traditions, in- 
cluding religious traditions. It is important that 
we look at not only the mental, physical, and 
emotional piece but also the spiritual piece when 
we are developing our instruments. 

Since 1963 there has been a lack of perception 
of meaning and significance, purpose, and be- 
longing among individuals in U.S. society. There 
has been an increase in alcohol, tobacco, and 
other drug abuse. There has also been increased 
exposure to negative role models. 

Television advertisers are taking a look at how 
to best get the attention of youth. Advertisers and 



1 58 National Conference on Drug Abuse Prevention Research 



researchers have found that if we target that part 
of our brain where emotional experiences are 
stored, the responses will be long-lasting and will 
drive our children to want to purchase and con- 
sume a product. An excellent book by David 
Walsh, called Selling Out America 's Children, 
describes what is happening in the world of elec- 
tronic media and how it influences us and breaks 
down some of the spirituality that exists within 
our communities. 

Indigenous healing methods include the use of 
folk medicine and its remedios (remedies) and 
yerbas (herbs) and the different ways that we 
work within our communities in terms of health 
and health promotion. Some research has indi- 
cated that if promotores, the natural leaders in 
our communities, are taught and then conduct 
assessments and initiate different programs, they 
are much more effective than a skilled or trained 
individual from outside the community because 
they are already trusted and known within the 
community. 

As I mentioned earlier, a key component of the 
cultura or culture of the different Latino peoples 
throughout the United States, as with the 
African- American community and the Asian and 
Pacific Islander community, is spirituality. As we 
look at a medicine wheel and at what our indig- 
enous brothers and sisters have taught us, we see 
that to maintain that balance and an effective 
human element within our communities and 
within ourselves, we need to use this particular 
orientation when we are conducting research. 

I have a few recommendations in terms of re- 
search, policy, and laws within the Hispano- 
Latino population. The indigenous concept of law 
is important to consider because it seeks out the 
honesty to point ourselves in the direction that is 
the ideal. For example, in Germany they have 
thousands of traffic laws because they are very 
precise in what they do, and they also have thou- 
sands of accidents. In Italy they have four laws 
and almost no accidents. Their four laws are, 
"Keep moving, be creative, don't kill anyone, 
and stay on the road." If we keep things simple, 
we get the effect we are looking for. 

To that end, we need epidemiological research 
regarding the health status of the various 
Hispano-Latino populations. We need to look 
at the natural support systems within the 



communities and have some of the research fo- 
cus on those particular elements that are consid- 
ered informal in the scientific sense. We need to 
take a look at the family program and the evalu- 
ation that is needed to determine which factors 
are associated with successful outcomes for cul- 
turally diverse populations. 

I want to impress upon you again the need to 
include the whole concept of spirituality. The lack 
of spirituality is moving this whole country in a 
way that is destructive, a way in which we see 
things more materialistically and individualist- 
ically. In the indigenous ways of living success- 
fully, materialism and individualism had no 
place. Instead, successful living was based on 
answering questions such as, "How can we cre- 
ate a healthy community for all and how can we 
work with one another and save the lives of our 
kids?" 

Thomas J. Connelly 

President 

Life Skills Training Curriculum 

This is an interesting year in my life. Two very 
significant things have happened to me. One was 
that the last of my children have graduated from 
either college or medical school. Free at last — I 
actually went out for dinner last night, paid cash, 
did not pay by credit card, and ate red meat. The 
second most significant thing that happened to 
me is that after 31 years in public education, I 
retired. I am in the process of developing a con- 
sulting business to work with school districts 
around the country. I was going to sit home and 
watch "Oprah," but I could not do that. So this 
evening, I leave for Anchorage, AK, to begin 
some work there. 

As I look at these past 30 years, I reflect back on 
my career in education. Any of you who work in 
education or know about educators know that we 
are pretty much "bonded" to our schools. I re- 
member my first year as a principal of a large 
high school of about 3,000 students in 1983. The 
staff of the school started coming to my office, 
saying, "Hey, Connelly, we have some problems 
here. We are seeing more kids pregnant. We are 
seeing more kids using drugs. We are seeing more 
violence in our schools." What they were saying 
was that they were seeing more aggression, not 
physical violence. "We need to do something 
about this," they said. 



Panel Presentations 159 



Not having tenure at the time, I thought it was a 
good idea for me to go to my school board at a 
public meeting and inform them of this problem, 
which we had not formally surveyed. I went to 
my board of education meeting, and I introduced 
myself as a principal of one of the high schools. 
I said, "We have a problem. We need to do some- 
thing proactively rather than reactively." But it 
fell on deaf ears, if you know what I mean. So I 
went back on a second Tuesday night and gave 
the same spiel. I got a little energetic and started 
waving my finger, but I don't think they liked 
that very much. On the third time I went back to 
my school board meeting, I was reprimanded by 
the president of the board of education and told 
that I should not air my "dirty laundry" in pub- 
lic. That began my career, not only in the field of 
public administration — education administra- 
tion — but also in the implementation of programs 
in my district. That Tuesday night I was devas- 
tated, and I was convinced that tenure would 
never come my way. On Thursday night of that 
same week, the senior-class son of the president 
of the board of education left school early, went 
home, turned on Pink Floyd's "The Wall," and 
blew his brains out after taking LSD. 

In my community, as in many of the communi- 
ties I work in, to have any kind of change — be- 
cause in education sometimes "change" is a dirty 
word — you have to have a crisis. Unfortunately, 
that is what happened in my community. The 
school board decided that they were going to do 
something. They posted a position for director 
of special counseling programs. That position 
was to do a number of things: oversee all pre- 
vention efforts, intervention efforts, and 
postintervention efforts; develop and supervise 
alternative schools for kids who were having 
adjustment problems in regular school programs; 
train teachers in how to deal with these issues; 
and reach out to the community, not only to edu- 
cate the community but also to ask for help. 

This was long before the availability of drug- 
free school money, long before some of those 
wonderful things that started to happen in the 
research. When they posted that position, typi- 
cal to education, there was no funding. So I took 
that position, and I was doing that for the past 
14 years until I retired. Each day of my life work- 
ing in this area, I dealt with — and I deal with — 
the issues of this terrible problem. 



But I remember my dreams at the time when I 
first took the position, before I had the research 
of Gil Botvin, of Hawkins and Catalano, of 
Emmy Werner. There was a void out there, and I 
remember that on the first day that the job was 
posted in the newspapers, one of our board mem- 
bers said, "We don't need that position. All we 
have to do is bring dogs into our school, and we 
will solve the problem." I remember having con- 
sistently bad dreams that each morning I would 
get up and go to my large kennel in the backyard 
and pick the drug dog of the day to go home with 
me. One night, my dog Scobie fell asleep in the 
back of my pickup truck and when he stuck his 
head through the window halfway across the 
bridge to work, I thought the nightmare had come 
true. 

Part of what I would like to do here today is talk 
about some of the ways in which we implemented 
programs in our school district, about what I 
am beginning to see after spending 30 years in 
one system, and about what I am beginning to 
see out there in America — some of the trends and 
some of the great success stories due to some 
of the great work done by NIDA and other 
agencies. 

My background is teaching chemistry, so I ap- 
preciate the research. I was trained to understand 
that one of the things you need to do is to base 
whatever you are doing on the research, and as I 
began to look up all of the good information, I 
came across this wonderful program by Gil 
Botvin. What it said made sense in relationship 
to the other research that was out there, which is 
that you can prevent this problem. I would like 
to give you a sense of how we began to look at 
this. 

After doing an extensive survey, or needs assess- 
ment, it was clear that our community had a prob- 
lem. Many problems that we identified centered 
around the issues of early first use of gateway 
drugs, primarily tobacco. Our assumption was 
that if we could reduce the number of kids using 
tobacco, we could reduce the number of kids 
using drugs from that point on. We understood 
that we had to involve the school, community 
organizations, parents, law enforcement, stu- 
dents, and community support systems. At that 
time, the faith communities were, and still are, 
part of our efforts. It was clear to us that without 



160 National Conference on Drug Abuse Prevention Research 



those significant players, we could not succeed 
in what we were intending to do. 

Believe it or not, the one area that seemed to be 
the most difficult to get into this process of pre- 
vention was the schools. Over the past 15 years 
of doing this, it has been a whole lot easier for 
me — and I can say this as a public educator — to 
motivate other organizations. My great challenge 
until the day I retired was getting schools to 
change. We wanted to develop primary preven- 
tion programs, secondary prevention programs, 
early intervention, late intervention, and after- 
care. The core issue was to develop a foundation 
on which we would build everything else. In 
education, that foundation was the prevention 
curriculum, beginning early in kindergarten and 
going through high school. In some cases now, 
we are into preschool. 

We presented the concept to the school system 
and to the community in a series of three boxes. 
In one box were all of the programs labeled as 
prevention. In the second box were intervention 
programs, and the third box contained aftercare 
programs. 

The primary prevention program in the preven- 
tion box was the Life Skills Training (LST) pro- 
gram at Cornell University. When we started to 
evaluate the success of that program, we noticed 
a dramatic change. We had about a 15- to 20- 
percent higher use of cigarettes and nicotine in 
our school system than any other school system 
in New York State. But after the second or third 
year, when we started our new needs assessment, 
on average we started to measure a 15- to 18- 
percent reduction in use of marijuana by students. 

Over time, we started to notice students who were 
moving into our school system who had never 
had the LST program. Giving them a Justice 
Department program called "Smart," we began 
comparing the students who had had the LST 
program with those who had not had the pro- 
gram. What was the difference? Clearly, we no- 
ticed that the kids who had been caught smoking 
in the schools were kids who did not have the 
Life Skills Training. 

What did we learn? The programs have been 
successful for 15 years, and we have data that 
consistently show we have made a difference. 
We still have some problems, of course, like most 



communities. It is clear to me as I travel to vari- 
ous communities throughout this country and the 
rest of the world that there has to be some kind 
of rationale developed with communities for 
doing this. I went to Guam about 4 years ago to 
implement a social skills program there for the 
Catholic schools, and I found that there were is- 
sues that were being ignored. I came up with the 
concept, which I brought back to my school dis- 
trict, of "Pay me now, or pay me later." The idea 
is that this problem is not going to go away un- 
less a concept is developed about how to solve 
it. 

To do that, basic components are needed: (1) a 
rationale for setting up programs; (2) an evalua- 
tion and a needs assessment to ascertain the 
nature of the present problem so that a determi- 
nation can be made later about whether you have 
made a difference; (3) implementation, or core 
programs that embody the results of research; 

(4) someone to monitor that program; and 

(5) someone to reevaluate it. 

Many communities that have started programs 
but no longer continue them need to know about 
the success stories, the data associated with those 
success stories, and what they need to change to 
become more successful. 

Over the past 15 years, the most difficult part 
about implementation was convincing the com- 
munity and my colleagues that this could work. 
That continues to be the major challenge for me 
in working in school communities. The challenge 
is to identify a problem and make people under- 
stand that the problem is not going to go away. 
"Pay me now or pay me later," but you are going 
to pay for this problem one way or the other. 

Another challenge is to set up programs that are 
based on the research, act as foundations for all 
other programs, are comprehensive, and work 
according to the research. An additional chal- 
lenge is getting someone in a school commu- 
nity — now it is a team approach, but it used to 
be an individual — to make sure that programs 
are sustained. Someone is needed to monitor 
those programs and conduct the evaluations, 
and someone else is needed to take that infor- 
mation and cause change to happen on an 
ongoing basis. 



Panel Presentations 161 



As I drove across the bridge leading across the 
Hudson River going to the school district for my 
first day 30 years ago, I was lost. I did not know 
the location of the high school where I was go- 
ing to teach chemistry. As I drove through my 
very large school district, I noticed children on 
street corners with name tags on, with moms and 
dads out there supporting them on their first day 
of school. When I observed those kindergartners 
on their very first day waiting for the school bus, 
my fantasy at the time was, "Wow! Someday that 
kid is going to be in my classroom. Someday I 
might teach that kid chemistry." For about 30 
years, the first day of school was a significant 
one, because I would purposely drive through 
my community and look at those kids with name 
tags on. 

On the first day of my last year in public educa- 
tion, I spoke to a group of guidance counselors I 
had hired for one of our high schools. My in- 
struction to those guidance counselors was, "Lis- 
ten: You need to know that you can't sit in your 
classroom or office and wait for kids to come to 
you. You need to be out and about dealing with 
these issues." 

Later I headed toward that high school where 
two of the new guidance counselors were out 



there talking with their students rather than wait- 
ing in their offices. As I drove toward the high 
school through the same community in which I 
had worked for 30 years, two police cars passed 
me, then an ambulance, and then another 
ambulance. 

When I pulled into the driveway of the high 
school, all the police cars and ambulances were 
parked in front of the school. As I walked into 
the guidance office to greet the two new guid- 
ance counselors, I observed them sitting on the 
couch in shock, because on their first day they 
had observed a student who had just come into 
our school district who had dropped acid. The 
student had gone to the guidance office, pulled 
out two knives, and stabbed to death one of his 
classmates. 

I said, "On my first day of my first 30 years, my 
concern was about having enough sodium bicar- 
bonate to do the first workshop and enough test 
tubes and glassware." Today I think about the 
challenge to some of the educators with whom I 
work, what their first day was like, and what their 
30 next years are going to be like. 



162 National Conference on Drug Abuse Prevention Research 



OPEN FORUM AND 
CLOSING SESSION 



Introductory Remarks 

Alan I. Leshner, Ph.D. 

Director 

National Institute on Drug Abuse 

This part of our program is one of two tests of 
whether you have done your homework assign- 
ments. Don't be nervous. This meeting is an op- 
portunity for NIDA to hear from the scientific 
community and obtain help in shaping a research 
agenda. We want to take advantage of people's 
experience and try to help bring research into 
the community. There are five work groups, and 
much of the purpose of this session is to hear 
back from these groups. 

We also hope that you took your other home- 
work assignment seriously. Please give your 
comments or your marked copies of the draft 
manual to the people at the registration desk. 

To moderate this session and to set the stage, we 
are fortunate to have another of the major lead- 
ers in the U.S. and international drug abuse and 
addiction prevention communities. He is diffi- 
cult to introduce because everybody knows him. 
So, I have to tell you two stories. 

When I first became the NIDA director, I made 
courtesy visits to all the leaders in the field, in- 
cluding this guy named Copple, who says, "I'm 
glad to see you because when I came to town 
somebody referenced some NIDA thing and I 
said, 'What's a NIDA?'" Copple had only been 
in the field for 20 years. 

I have taken that, "What's a NIDA?" as a per- 
sonal challenge, and I am hoping that at least the 



people in this room have figured out "what's a 
NIDA," who we are in the process, and that we 
are, in fact, being useful. 

The other thing I want to tell you about Jim 
Copple is that he has been personally respon- 
sible for providing tremendous leadership in the 
development of what is now a gigantic, inter- 
connected network among coalitions in this coun- 
try. In 1992 the President's Drug Advisory 
Council declared there should be coalitions and 
that there should be a mechanism to coordinate 
the establishment of those coalitions. They are 
now everywhere, and I think the data are clear 
that they are tremendously effective. 

I also discovered, after meeting this guy, that he 
has a bachelor of arts degree from Eastern 
Nazarene College and a master of divinity de- 
gree in church history from the Nazarene Theo- 
logical Seminary. This is trained leadership. I 
give you one of the leaders of our field, Jim 
Copple. 

How Can Prevention Research 
Help the Community? 

Moderator: 

James E. Copple 5 

President 

Community Anti-Drug Coalitions of America 

It is a pleasure for me to be here, and this, I be- 
lieve, is an extremely important topic in an im- 
portant conference. 

My 14-year-old daughter, Jessica, is one of the 
Nation's leading antidrug warriors, and some of 



5 At this printing, Mr. Copple is director of Coalition, State, and Field Services, National Crime Prevention Council. 

Open Forum and Closing Session 163 



you have met her at the National Leadership 
Forum. I talked to her on the phone last night, 
and she said, "What are you doing tomorrow, 
Dad?" 

I said, "Well, I am speaking at the NID A confer- 
ence." 

She said, "That is a good organization." 

I said, "You know about NIDA?" 

And she said, "You forget. Remember second 
grade?" 

And I said, "Oh, I remember second grade." 

Jessica had come home from school, and her then 
14-year-old sister was sitting at the table. Jes- 
sica was in second grade and had just gone 
through an extensive drug program at school. We 
were having tacos that night, I remember, be- 
cause it was one of the only times we drank Coke 
with our dinner. But Jessica was not drinking 
Coke; she was drinking water. And Jessica is a 
nonstop talker. You know how with your chil- 
dren you develop that ability to screen out and 
sort as they are talking? So we are sitting there 
at the table, and finally her older sister looks at 
Jessica and says, "How come you're not drink- 
ing Coke?" Jessica says, "That stuff will kill 
you." I kind of looked at her, but did not pay too 
much attention to it. 

We went about our dinner — this is a scene out of 
"Father Knows Best." The table was cleaned off, 
and I go into the living room and sit down to 
read. As my wife sits down to read, we hear Jes- 
sica in the kitchen. We hear all this commotion 
every once in a while, but we were just kind of 
screening all this out. 

Then we hear, "Oops!" That is one of those 
phrases, so her mother and I got up. We walked 
into the kitchen, and the kitchen is a mess. There 
are coffee grounds spread everywhere, and Jes- 
sica is standing on this stool with this huge can 
of Coke pouring it down the sink. 

I said, "Jessica, what are you doing?" 

She said, "I'm doing an interjection." 

"An interjection?" I said. 

"Dad, this stuff has caffeine in it. Let me tell you 
what it will do to your heart, what it will do to 



your brain." And she starts going through all this 
stuff. 

I ask, "Where did you get this?" 

She says, "Let me show you this factsheet," and 
so she gives me this factsheet given to her by her 
teacher, and at the bottom it said, "NIDA." 

I said, "Well, Jessica, I do not think it is an inter- 
jection. I think it is an intervention, but you're 
messing with my drugs." 

Another quick story about Jessica. Some of you 
have heard me. tell this, but it makes a point re- 
lated to prevention research and community or- 
ganizing. As a community organizer and having 
led a local coalition, I only cared about research 
that could help me do my job and help me be 
more effective. I cared about research that would 
help me influence policymakers, help me raise 
money, and help me make change — some of 
those real tangible things coalition leaders in this 
field have to deal with every day. 

I am divorced, and Jessica lives with her mother 
in Baltimore. About 2 years ago when Jessica 
was 12, we arrive at the designated meeting spot, 
and Jessica and her mother are in the car crying. 
Eileen rolls down the car window, looks at me 
and says, "When are you going to solve the drug 
problem?" This, too, is my fault, right? 

I said, "What are we dealing with here?" 

She said, "Well, Jessica spent the night at 
Stephanie's house last night, and Stephanie of- 
fered her marijuana. Stephanie's older sister of- 
fered her cocaine." 

I said, "You're kidding me! Are you okay, 
Jessica?" 

She said, "Dad, I am so disappointed. I am so 
upset. Stephanie is one of my closest friends." 

I said, "What happened?" 

She said, "Well, Stephanie started smoking the 
marijuana." 

We have this phone code system that we use 
when one of our kids is in crisis. They always 
say, "I have got to call my parent to ask about 
Granddad. He is sick." That is the code for "Get 
your butt over here and pick me up." 



164 National Conference on Drug Abuse Prevention Research 



Jessica used the code, and Mom picked her up. 
So I get in the car and say to Jessica, "Jessica, 
what did you tell her?" 

She said, "Well, I told her I didn't want that stuff, 
and then, Dad, I told her everything you taught 
me."' 

I said, "Good. Tell me." 

She says, "I told her that marijuana causes short- 
term memory loss. I told her that the THC con- 
tent in marijuana is worse today than it ever was 
in the 1960s. I told her it affects motor skills and 
coordination. And then, Dad, I told her some- 
thing else I am not too sure is accurate." 

I said, "What is that?" 

She said, "I told her it stunts breast growth." 

I said, "Jessica, why did you do that?" 

She said, "For a 12-year-old, Dad, that is impor- 
tant information." She is a community organizer 
after my own heart. I do not know if there is any 
research on this, but we need it. Jessica is out 
there in the field, and her reputation is on the 
line; this could be a powerful tool. 

Community organizers are desperately in need 
of research that effects change and that is writ- 
ten and communicated in a way that effects 
change. That is one of the reasons I am excited 
about the work NIDA is doing in this conference. 
Organizations like the National Center for the 
Advancement of Prevention (NCAP) are captur- 
ing research and advancing materials and put- 
ting them into the hands of practical people who 
are working day in and day out. 

To me, research must be captured for three things: 
decisionmaking, responsibility, and control. That 
is, we need to have the kind of research and data 
that helps us make programmatic decisions in 
the field as to what works and what does not in 
the continuum from prevention education, treat- 
ment, and law enforcement, to continuing care. 
We have to convince local policymakers that our 
strategies, tactics, and decisions about program 
choices do work. 

I must confess, I never spent a lot of time evalu- 
ating whether a particular strategy was going 
to work until I met the evaluator who was as- 
signed to me by the foundation that was support- 
ing our coalition. I can remember headlines in 



the news when we had a reduction in our com- 
munity in marijuana and cocaine use at a time 
when everything else was going up. When we 
met with our evaluator, four foundation repre- 
sentatives were there. The evaluator put charts 
up on the board that were flat in terms of coali- 
tion activity and coalition involvement. 

I asked him one of the most important questions 
I had asked in that relationship: "If these charts 
are so flat, then why am I so tired?" And the 
founder, the funder of the coalition, and the head 
of one foundation said, "That is a good ques- 
tion. We see some data that are showing decreases 
in marijuana and in cocaine — in crack cocaine 
specifically — and the coalition has put a lot of 
activities in there." He simply was not capturing 
it, and we were not reporting it in a way that the 
two could mix. We need great local intervention 
research to inform and affect our decisionmaking 
about what programs we should support. 

In the past 18 months as CADCA (Community 
Anti-Drug Coalitions of America) has taken off, 
I discovered that I am under siege by curriculum 
vendors and others who want me to promote their 
products, but I do not have the foggiest idea 
whether their products work in the streets. I need 
help making decisions. 

Another issue is responsibility. Many of us are 
out there responding to one critical incident af- 
ter another. A coalition leader goes to work and 
tries to figure out to which direction he or she 
should bow. As a coalition leader, I knew it was 
a good day when the chamber of commerce presi- 
dent took me to breakfast and said, "Copple, you 
are in bed with all those neighborhood groups 
that have their hands out." That night at a com- 
munity town meeting, a neighborhood leader 
stood up and said, "Copple, the problem with 
you is you are in bed with the chamber of com- 
merce." After I informed my wife that I was 
sleeping around, I realized that I had all this stress 
and pressure from these different groups look- 
ing for outcomes. We are constantly being put 
into a position of having to respond, but we need 
the ability to respond in a way that is thoughtful, 
provocative, and effective. 

In my judgment, the researchers in this room have 
a responsibility and an opportunity to give us data 
that allow us to respond in a way that makes sense 



Open Forum and Closing Session 165 



in the local community and to express it to 
us in a way that gives us real data and some real 
intelligence. 

Another issue is control. It is a question of our 
assuming control of our communities, because, 
quite frankly, I am weary of national surveys and 
national data on communities. When I was lead- 
ing a local coalition, I would be driving to work 
and listening to National Public Radio. When I 
would hear that such-and-such organization just 
released their national data, I would say to my- 
self, "Oh boy, here we go." I would walk into 
my office, and there would be five calls from the 
local press asking, "What does this mean? Tell 
us what this means. Interpret this for us." And I 
had not even seen the survey. 

In the past month, more than 4,000 community 
coalitions were surprised by the release of three 
major sets of survey data, and people called our 
office asking for help and interpretation. Data 
must be sent to the communities so that the com- 
munities can respond and react meaningfully. If 
it is about promoting stories and organizations, 
we can help you do that. We can extend the story 
2 or 3 days. Many community activists are not 
as stupid as we sometimes think we are. We can 
figure this stuff out, and we even have universi- 
ties in our local communities who can help us 



figure it out. We have evaluators who can help 
us figure it out. 

Send these data to us in a way that we can ex- 
tend the story and tell it in a meaningful way in 
the local community, because my mayor does 
not care about national data. He cares about 
Wichita, KS. When I stand in front of a local 
policymaker, he or she wants to know what it 
means for Wichita, and that is when I need the 
capability, tools, and guidance of organizations 
like NIDA, NCAP, CSAP, and others. I need tools 
to help me to do that local storytelling in a way 
that documents and presents real, live commu- 
nity change. 

Thank you for the invitation to be here, and Jes- 
sica also thanks her "good" organization. And if 
we ever get the data on breast growth and mari- 
juana, we will have a hit. 

I must underscore that I am impressed that this 
conference is happening and that there is a com- 
mitment to make prevention research real for 
communities. That means a lot to those of us who 
have worked in communities and are working in 
community collaboration, because you are pro- 
viding tools that will help us make local policy 
and program changes. I think in the long run it 
will be effective. 



166 National Conference on Drug Abuse Prevention Research 



Work Group Reports 



Work Group on Risk 
and Protective Factors 

Robert J. Pandina, Ph.D., Reporter 

The remarks that came out of our work group 
are summarized in seven points that fit nicely 
with themes that have been articulated this morn- 
ing. These points are not listed in order of priori- 
ties, but in order of how and when they came up 
in the conversation. 

First, there is a desire and a need for behavioral 
engineers to help translate and adapt current pre- 
vention models to the many diverse potential pre- 
vention venues. The real challenge presented in 
our group was whether the building blocks de- 
rived from what I am going to term the "proto- 
type models" that we have built over the last 
decade can be extended to all segments and set- 
tings of those in need of prevention activities. 

Second, we need to determine if other viable 
models exist. That is, are there important ap- 
proaches that have evolved from a grassroots 
community level that could be viable in dealing 
with the vast prevention needs in the country? 
We need to characterize and evaluate these; there 
was a need on the part of the people who were 
developing these grassroots models to have them 
evaluated and characterized. 

It also came out of our discussion that we may 
have to adapt the evaluation paradigms that we 
currently use to try to capture these models and 
test their viability in a way that we are not cur- 
rently equipped to do. This may require new 
evaluation tools to give these new models a fair 
test and evaluation. 

Point number three speaks directly to an issue 
that Mr. Copple raised this morning. There is an 



apparent gap in communication between the pro- 
totype model developers and all levels of con- 
sumers, whether they be communities, States, or 
local organizations. There is a need to somehow 
close this communication gap to bring us to- 
gether. I thought that the remarks of Dr. Johnson 
this morning were on point with regard to that 
issue. There appears to be an evolving national 
network that would permit a catalysis of this clo- 
sing of the gap among the various segments of 
prevention-concerned communities. It will be 
interesting to see whether there is a way we can 
catalyze the closing of this gap through NIDA 
and other organizations and individuals that are 
sponsors and participants in this conference. 

The fourth point is a perceived need for greater 
organization, coordination, and assistance in in- 
terpretation of the data provided by diverse in- 
formation sources, particularly about the nature 
and extent of risk and protective factors, the na- 
ture of the problems, and the nature of the solu- 
tions and their applicability across the broad 
venues in which prevention programs occur. This 
includes a dissemination of evaluation results, 
and I think this is right on target with what you 
have asked for in your remarks to us. 

Fifth, there is a need to develop an ongoing pro- 
cess, possibly [a new] organization or utilizing 
established organizations, to directly link re- 
search and researchers to potential consumers at 
all levels — local units, community alliances, 
school-based programs, concerned politicians, 
and others. Again, we need some way to cata- 
lyze this process of communication. It seems that 
the building blocks are all in place. They are all 
rubbing up against each other, but the neural 
growth has not occurred yet. 



Work Group Reports 167 



Sixth, there is a need to provide systematic tech- 
nical assistance to extend prevention evalua- 
tion — not just prevention programs but 
prevention evaluations — to all venues in which 
prevention programs occur. A point was made, 
likely a valid point, that many local programs 
have short-term funding and that it is almost 
impossible within the confines of such funding 
to get a program up and functioning, let alone to 
conduct a meaningful evaluation. There is a real 
need perceived by the individuals conducting the 
program — not the scientists, not the evaluators, 
but people conducting the program — for a way 
to evaluate and demonstrate the efficacy or, can- 
didly, the inadequacy, of the programs that were 
delivered, so that the programs can be improved 
and disseminated at the local level. 

The seventh and last point on which the group 
had some consensus was the need to better 
specify the distinctions within risk factor mod- 
els, particularly the need to characterize protec- 
tive and resilience factors and processes. We need 
to better specify what these factors are and to 
provide a clear understanding of them for the 
individuals who have to make use of these fac- 
tors. This includes the differences between mark- 
ers and mediators and how they work as 
processes, with particular emphasis on identify- 
ing the nature of the resilience process. This also 
ties in with some of Dr. Leshner's remarks about 
the need to emphasize protection and what things 
may inoculate communities or individuals or 
settings. 

Work Group on Critical Factors 
for Prevention Success 

William B. Hansen, Ph.D., Reporter 

Our work group developed a "top 10" list of criti- 
cal factors and recommendations for prevention 

success: 

• Recommendation Number 10: Moving from 
science to practice remains a challenge. There 
is a need for continuing training, education, 
and communication. 

• Recommendation Number 9: Oregon has 
mandated prevention services as part of its 
managed care contracts. I think that is a point 
worth noting. 



• Recommendation Number 8: 1 want to quote 
this as closely as I can. "There are data, and 
then there are data." Evaluation must start 
with meaningful activities where information 
is truly useful. 

• Recommendation Number 7 : Involving youth 
in community service is a naturally available 
alternative that is protective and creates a 
natural high. 

• Recommendation Number 6: Some commu- 
nities are just not ready for prevention; how- 
ever, they will take money for prevention, 
even if they do not do anything with it. We 
need to do research on how to promote com- 
munity readiness. There are some communi- 
ties that are in denial, and there are some 
communities where drug abuse does not even 
enter the radar screen. 

• Recommendation Number 5 : This is duplica- 
tive, but if you can hear it enough times then 
maybe you can catch this: Local community 
research needs funding. It has no funding. It 
has to be a high priority. It involves getting 
things from selected sites down to local sites 
where local decisionmakers can actually make 
decisions. 

• Recommendation Number 4: Being data- 
driven does not necessarily mean ignoring 
theory or intuition, and it does not mean be- 
ing atheoretical or being counterintuitive. 
Both theory and intuition are needed with the 
data. 

• Recommendation Number 3: Logic models 
can help guide policy and evaluation. There 
was an after-session meeting that crystallized 
this [idea] that people in my earlier session 
might not have caught. Science can tell us a 
great deal about prevention. What if we have 
not done evaluations yet? Can science still 
help us evaluate the things that we have done, 
things that we are proposing to do? Yes, it 
can. Logic models are embodied in many of 
the things that Elaine Johnson talks about and 
a lot of the work that community partnerships 
and coalitions have been trained to do. This 
involves listing things that are equivalent to 
risk and protective factors and then seeing 
how the programs that we are addressing 



168 National Conference on Drug Abuse Prevention Research 



match up with that list. This can be a valu- 
able tool for communities to use. 

• Recommendation Number 2: Not everything 
we do should be evaluated. Somebody said 
that. It stuck in my head, so I thought I would 
report it. 

• Recommendation Number 1: When consid- 
ering a response to rising inhalant use, we 
need to focus on education rather than legis- 
lation. Also, legalizing marijuana would send 
the wrong message to youth and would inter- 
fere with education. 

Work Group on Prevention 
Through the Schools 

Gilbert J. Botvin, Ph.D., Reporter 

Our work group felt it was important that pre- 
vention be science based, and I wanted to under- 
score the importance of using the appropriate 
prevention methods and appropriate teaching 
methods for implementing prevention programs 
in the schools. 

Group members also wanted to emphasize the 
importance of using a consistent prevention mes- 
sage, multiple prevention channels, multiple 
modalities, and multicomponent approaches. 
They felt that, although there had been a great 
deal of emphasis on school-based interventions, 
even school-based interventions must consider 
the parents and must foster more parental in- 
volvement. There were some concerns raised in 
our group about how to handle kids from dys- 
functional families, especially from families 
where either one or both parents may be drug 
users themselves, or from families where the 
parents may be 16-, 17-, or 18-year-olds. 

Work group members discussed the need to fos- 
ter the involvement of other stakeholders in the 
community and to reach out to community lead- 
ers, parents, and other organizations that can help 
support the effort of the overall community. 

They also want to emphasize the inadequacy of 
a "sloganish" approach to prevention and the sim- 
plicity that is conveyed in slogans like, "Just Say 
No," or the most recent slogan, "Just Don't Do 
It." That is not enough; we have to take into ac- 
count the whole child. 



The work group also discussed the need to think 
seriously about the role of peer socialization, tak- 
ing into account psychological factors and issues 
related to normal child and adolescent develop- 
ment, so that we foster the healthiest and most 
successful children that we can produce. 

There is the need to move away from negative 
language, such as military metaphors like the 
"war on drugs," and to move toward a more posi- 
tive, growth-enhancing approach and a more 
positive, growth-enhancing message with respect 
to prevention. 

Although we talked about wonderful prevention 
programs, including the Life Skills Training that 
I talked about yesterday, work group members 
expressed a good deal of concern that there are 
significant barriers not being addressed. Issues 
of training and implementation fidelity can be 
addressed fairly readily, but there are other bar- 
riers that are more formidable, such as the ad- 
equacy of funding for prevention programming 
on a local level. Work group members expressed 
concern about curriculum time requirements and 
how to do interventions that must take up a sub- 
stantial amount of time if they are to be effec- 
tive. Concerns were raised about how to reconcile 
that with pressure to achieve academic goals and 
improve academic standards. 

There was a consensus about the importance of, 
and a tremendous thirst for, information about 
proven approaches that can help give people a 
sense that they are on the right track, and that 
they are doing the right thing. This can help to 
reenergize community prevention efforts that are 
being done more and more with fewer people 
and with fewer resources. 

Finally, there was a concern that, although there 
have been advances in working with minority 
populations, we need a better understanding of 
the needs of minority kids, the kinds of preven- 
tion approaches that can be effectively used with 
these populations, and ways to tailor those ap- 
proaches so they satisfy community needs. 

After summarizing those general concerns and 
issues, as was our charge, we came up with some 
recommendations, which are not presented in 
priority order: 



Work Group Reports 169 



• There was a feeling that prevention has to 
have a different posture and has to ascend 
more to the national agenda, not just in terms 
of all of the negative statistics. Drug abuse 
prevention must be a national priority on the 
same level as national immunization. It has 
to be something that occurs for all kids all 
over the country and is taken seriously. Drug 
abuse prevention has to be funded. There must 
be a consistent and sustained effort to do the 
most effective prevention programs in com- 
munities around the country. This interest in 
prevention on the part of the general public 
and on the part of the media must not rise and 
fall from day to day, becoming a "hot issue" 
only during this political season. It must 
outlast the political season, and we must move 
with sustained effort. 

• A national effort has to involve cooperation 
of relevant Federal agencies, and there was a 
great deal of concern over the lack of inter- 
agency cooperation. We have several agen- 
cies represented here, but there was concern 
expressed that the Department of Education 
is not here and that a lot of Government agen- 
cies have a stake in drug abuse prevention but 
are not working with the necessary collabo- 
ration. Some effort is needed to pull together 
Federal agencies and perhaps to form a coali- 
tion among agencies such as NIDA, the De- 
partment of Education, CDC, CSAP, and even 
the Department of Defense to work together 
in a coordinated way with the same mission, 
singing the same song, and marching to the 
same beat. This may be an impossible task, 
but it is something that we should strive for 
nonetheless. 

• Going beyond this conference, there has to 
be an intensive effort to disseminate informa- 
tion about what works, including such ideas 
as regional seminars around the country. Our 
group felt that it was necessary to "take the 
show on the road" with workshops to provide 
training and some mechanism for providing 
technical assistance. Members recommended 
collaboration with national coalitions and 
national organizations in the area of preven- 
tion and education. 



There was great concern about the need for a 
funding mechanism to make training and pre- 
vention materials available and the need to 
give schools financial incentives to use the 
right programs. Unfortunately, many people 
felt that, left to their own devices, some 
schools might have a somewhat venal ten- 
dency to use available money to plug holes 
in their own budgets rather than to implement 
the most effective and proven drug use pre- 
vention approaches. It was suggested that this 
could be averted — and there may be hisses in 
the group — by reallocating some of the money 
from the Safe and Drug-Free Schools budget 
to help support proven prevention approaches. 

Our work group recommended a formal col- 
laboration between the Department of Health 
and Human Services and the Department of 
Education, modeled after a program called the 
School-to-Work Opportunities Act, which 
provides a mechanism for financing and de- 
livering high-quality programs to schools in 
that arena. It was suggested that a similar kind 
of program could be developed on a Federal 
level to deliver high-quality drug use preven- 
tion programs to schools around the country. 

There must be a development of national pre- 
vention standards, again to increase account- 
ability on a local level and to ensure that 
people are using the most effective preven- 
tion approaches. There is also a correspond- 
ing need for some standard evaluation tools 
that communities can use, rather than all re- 
lying on major NIDA-funded studies. Some 
folks felt that they could do a lot on their own 
local level, and they want to have the ability 
to evaluate the many worthwhile things that 
they are doing. However, it was also acknowl- 
edged that there is already much duplication 
among the State and local surveys that are be- 
ing done by a variety of groups around the 
country. There has to be some way of coordi- 
nating all of these to get the kind of data that 
individuals need that can serve as a barom- 
eter for how their community is doing rather 
than conducting yet another survey that could 
easily be included in an ongoing survey. 



170 National Conference on Drug Abuse Prevention Research 



• Finally, there was a suggestion for consider- 
ably more money for research. 

Overall, the work group wanted to commend 
NIDA for putting together an excellent confer- 
ence to help communities and schools use the 
best science-based prevention approaches. The 
group members voiced hope that this conference 
would not be a single event but, rather, would 
become part of a major, sustained effort to dis- 
seminate effective, user-friendly, research-based, 
prevention approaches that can be easily utilized 
by communities throughout the country. They 
also expressed hope that we would see changes 
in the way in which prevention is done and the 
way in which prevention is currently funded. 

Work Group on Prevention 
Through the Community 

Mary Ann Pentz, Ph.D., Reporter 

With respect to general comments for success, 
the first point from our work group was the idea 
of the comprehensive, community, multicompo- 
nent approaches that we talked about yesterday. 
Surprising to me, there was consensus also about 
the utility of research. I can remember in the not- 
so-recent past when community coalitions said, 
"It is just a pain in the neck. Can't we just go on 
with our work and not evaluate our efforts?" I 
don't hear that anymore. There is an understand- 
ing of the need to use research as a tool, primar- 
ily for accountability for what you are doing and 
as a stepping stone for future funds. 

What was interesting about this acknowledgment 
of the need for comprehensive community in- 
tervention were the group's ideas about how 
to extrapolate it to other things besides mul- 
ticomponents. One of these was adding age 
groups, using a multigenerational program, not 
all at the same time. One example came from 
Gloucester. There is a lot of attention paid to 
Little League players, but when those Little 
League players get older, there is nothing for 
them. A lot of them are latchkey children, and 
they have a lot of time on their hands. The point 
was to look at different stages or age groups and 
develop prevention programs for them. 



Another recommendation was to interpret com- 
prehensive community intervention as contex- 
tual programming. It was the idea of taking the 
systems that are already in place and for which a 
community already has a budget — recreation, 
waste removal, transportation, local ordinances, 
schools — and fashioning prevention programs 
for each of those existing systems. This involves 
talking to each of those systems to get at least 
part of their budgets invested in prevention 
programming. I don't think we have done this 
before. 

The group also discussed adding worksites, both 
as a future research area and as a means to get at 
adult behaviors. This includes worksite preven- 
tion programs aimed at those who have just 
passed through adolescence, young adults, and 
adults who have young adolescent children. 

Another point was the need for a multicultural 
focus, and there was some discussion about how 
to do this with limited funds. There were several 
communities represented in our group that al- 
ready have several coalitions that can deal with 
prevention issues. It was suggested that each 
could target a different cultural issue. The coali- 
tion should have collaborative efforts with on- 
going agencies rather than turf battles, and the 
coalition in a community in which a program is 
run should recognize it as their own program. 
Failures and successes were mentioned with re- 
spect to outsiders coming in and not becoming 
part of the program in the community. There- 
fore, the program should be based on the 
community's acknowledging that it was their 
decision to adopt a program and to tailor it to the 
community if need be. 

The work group offered general comments per- 
taining to the role of the researcher. In the 
community-based work, when researchers are 
used, they are used as evaluators. However, there 
are other roles for a researcher, the first being an 
organizational consultant to communities, espe- 
cially during the needs assessment process. An- 
other role is that of an information broker about 
drug use, etiology, epidemiology, and principles 
that work in prevention, and providing that 



Work Group Reports 171 



information to communities. Still another role is 
that of evaluator. 

The work group explored the question of how to 
sustain an effort by community coalitions over 
the long term. A first suggestion was moving the 
interventions from context to context. A second 
is building in a plan to rotate community coali- 
tion personnel at the 2V 2 -year point to prevent 
burnout. The third suggestion was having the coa- 
lition and community representatives vote on 
whether the community should move after about 
a 3 -year period from a specific drug use focus to 
other problem behaviors that are related to drug 
use, so that problem behaviors, like violence, 
become more or less salient without loss of the 
drug use focus. The fourth suggestion was the 
notion of reinvention, which basically means tai- 
loring a program over time by restructuring it 
slightly, making corrections, and fine-tuning it 
like you would a car. It also involves acknowl- 
edging the people who are involved in the fine- 
tuning to provide reinforcement and encour- 
agement to continue their efforts. 

We also dealt with the problem of adults and 
changing their behavior, since they are models 
for children. The first suggestion was that, be- 
cause it is difficult to change adult behavior in 
Western society, we send children's messages 
home through prevention programs and exert 
positive pressure on parents through the child, 
particularly through homework activities. 

A second suggestion was a model used in inner- 
city Detroit, where using positive child pressure 
is a rather threatening occurrence. The model 
involved getting adults, especially those in hous- 
ing projects, to make a public commitment at 
the same time that children make a public com- 
mitment as part of a school program. The desig- 
nated adult who makes the commitment may or 
may not be a parent. A third example was, again, 
using worksite prevention programs to address 
adult behaviors. 

The work group also discussed how to regener- 
ate community interest in drug abuse prevention. 
This involved the issue of readiness and an ac- 
knowledgment that we may no longer have many 
communities at the point of readiness for drug 
use prevention. We have had several years of that. 
The question is whether we can regenerate or 



regear to make drug use prevention a focus. The 
discussion revolved around conducting a needs 
assessment now and strategically using mass 
media. 

Another issue the group discussed was how to 
enact policy changes at the community level. We 
did not have an answer for how to deal with big 
legislative hammers like the tobacco industry, 
and it is probably beyond the scope of the dis- 
cussion here. But there was an acknowledgment 
that the way to change local policy is to use pre- 
vention programs in the mass media to start 
changing perceived social norms. In this way, 
you build up a norm for the unacceptability of 
drug use, and it becomes easier to change local 
policy at some point. 

The work group also discussed turf battles among 
coalitions and agencies. Group members recom- 
mended the use of prominent, credible business 
leaders who can help remove the issue from a 
health agency domain. They also suggested mini- 
mizing the use of politicians unless there is a 
cohesive community council that will be behind 
prevention for a long time. 

We discussed how to generate long-term fund- 
ing, and this included charging schools a mini- 
mum of $2 to $3 per student, which is paid into a 
fund for delivery of prevention programs each 
year. This would also involve bringing businesses 
into coalitions but not systematically approach- 
ing them for donations each year. 

Finally, in regard to directions for research, there 
was a recommendation for more research on pre- 
dictors of effective coalitions and on the effects 
of coalitions on drug use changes. The research 
would involve building more in the way of doc- 
toral and postdoctoral training programs for re- 
searchers in prevention. 

Work Group on Prevention 
Through the Family 

Thomas J. Dishion, Ph.D., Reporter 

Our work group focused our comments on 
three areas: parent involvement and barriers, 
bridging the gap between research at NIDA and 
implementation in the community, and future 
directions. 



172 National Conference on Drug Abuse Prevention Research 



A representative of the National PTA was in- 
volved in our work group and pointed out that 
PTAs have noticed that parent involvement has 
been decreasing over the past 10 years. We need 
to be mindful and conscious of a significant bar- 
rier to prevention programs that aim at parents, 
and that there may be some structural constraints 
to parent involvement, such as parents' work 
schedules, that are significant barriers. Other 
barriers to parent involvement may be a sense of 
hopelessness, including subtle and not-so-subtle 
messages that parents cannot affect some of the 
problems in drug use and other problem behav- 
iors that are prevalent today. 

Another barrier may be the time and the type of 
demands we make on parents in our prevention 
programs. The 16-session, 2-hour-a-week par- 
ent groups are demanding and unrealistic for 
many parents, despite their good intentions. 

How might we get beyond these barriers with 
some positive solutions? The work group sug- 
gested that we limit the demands and time needed 
for interventions, be more focused, be briefer, 
and be more relevant as much as possible. 

It was suggested that we need more of a para- 
digm shift, that parents need to be involved at 
the policymaking level or at a level where we 
would have more parents attending meetings 
such as this one. Parents need to be included not 
only in the solution but also in [articulating] the 
problem. 

Another possible approach to increasing parent 
involvement is to "pitch" this problem more as a 
child-centered health issue and less as a drug use 
or violence issue. 

Most people did not select their prevention pro- 
grams on the basis of research for several rea- 
sons. First, research-based programs are 
expensive for most local implementers to utilize. 
Also, consumers often have trouble separating 
the passion of the research group from the use- 
fulness of the program. Another issue was that 
many other political, personal, intuitive, and State 
funding factors take priority. For example, State 
funding may be extremely important in deter- 
mining which strategy a community uses. 

Another barrier cited was the lack of informa- 
tion on details of implementation. It was sug- 
gested that a person or group at NIDA serve as a 



nexus between the research-based program de- 
velopers and the community implementers, and 
that person or group would conduct the work- 
shops. The workshops would be specific and fo- 
cus on training skills related to program 
implementation. There are many specific skills 
that groups have learned about getting parents 
involved that are often unreported and not taught; 
these would be included as part of the workshop 
or dissemination effort. We also could help dis- 
seminate the science by clarifying for the com- 
munity implementers the relationship between 
groups like CSAP and NIDA and other State 
block funding sources. Many communities do not 
know who to go to for their various needs. 

Another possible solution would be to develop a 
regular newsletter that provides concrete infor- 
mation or principles relevant to targeting parents 
or adults in intervention practices. NIDA does 
publish such a newsletter [NIDA NOTES] that is 
extremely helpful to researchers. The work group 
suggested another newsletter, pitched to the pro- 
gram implementer, that lays out principles more 
concretely. In this way, NIDA could help guide 
States in developing an infrastructure or frame- 
work for selecting prevention programs. This 
might be especially relevant to State block fund- 
ing systems. 

With respect to future direction in research, the 
work group discussed ideas about areas of re- 
search that would be particularly interesting and 
helpful to the program implementer. One key area 
would be pure research on program implemen- 
tation. We need more research on early interven- 
tion; many of the programs are aimed at 
childhood and adolescence. In addition, we need 
to better understand the effects of poverty on the 
basic family processes that we are targeting and 
also the effects of poverty and its disadvantages 
related to implementation of prevention pro- 
grams. We need research on the use of partici- 
pant education and participant workers in 
prevention, especially prevention programs di- 
rected to families. 

Another question of research interest is the im- 
pact of mandating parenting interventions. Mem- 
bers of the work group were concerned about 
working with children whose parent or parents 
are drug users themselves. What is the best way 



Work Group Reports 173 



to approach getting their involvement? Is it man- not an issue of poverty, but an issue of neglect, 
dated? Do we use incentives? It would be useful and drug use is certainly relevant in those set- 
to research and answer this question. tings. We need to better understand the dynam- 

„ 7 , , , Jt , . rt< n„ t <.„ ics and provide prevention resources there as 

We also addressed the issue of affluent neglect. r r 

There is a generation of children being raised in 

families where both parents are working. It is 



174 National Conference on Drug Abuse Prevention Research 



Closing Remarks 

Alan I. Leshner, Ph.D. 

Director 

National Institute on Drug Abuse 



The work group reports have generated some 
noteworthy suggestions, one of which is the need 
for local algorithms, an issue that is also relevant 
to the treatment of drug abuse. NIDA will be 
studying this issue because we are frequently 
asked to provide not only mechanisms for deter- 
mining local epidemiology but also mechanisms 
and approaches — algorithms — for conducting 
evaluations of the impact of local drug use pre- 
vention programs. 

The issue of the fox watching the chicken coop 
notwithstanding, it is possible for a local project 
to evaluate its program's effectiveness, perhaps 
using different evaluation mechanisms. One does 
not have to be an economist to do an economic 
analysis; that is, there are reproducible formulae 
and algorithms that can help, not by turning it 
into a research project, but by providing useful, 
credible information. Therefore, NIDA will be- 
gin working on ways to provide the tools to do 
that. I do not know in detail what that means, but 
I hear the need, and we will work on that. 

I was struck by the comment that "there are data 
and there are data," and I would remind you all 
that if we abuse the data, we lose our credibility. 

Another comment I was struck by feels similar, 
and that is, "There is talking and there is talk- 
ing." The emerging theme about the coalitions 
is important. They are not just "talking"; they 
are doing things together and trying to find a 
single song to sing. Unless we do that, we are in 
very deep trouble. 



I think we all agree that we are making tremen- 
dous progress. Without pointing out a particular 
place or a particular program, I was in a large 
city in the South with palm trees recently to at- 
tend a meeting of a well-known coalition. I was 
astounded, first of all, at the high level of people 
involved in it, and second, at the unanimity of 
what various groups were saying — the police, the 
Justice Department, the jailers, and the preven- 
tion and treatment providers. It was an overall 
policy thrust and policy message, and that is what 
we have to do. This conference marks a step in 
research that NIDA has been doing for many 
years, and I hope this conference is a major step 
in a direction that will continue. 

There is no point in doing research unless it is 
going to be used. The era of knowledge for the 
sake of knowledge ended decades ago. Because 
I was trained that knowledge for knowledge's 
sake was good, I gave a talk one year at a meet- 
ing of the American Association for the Advance- 
ment of Science, an elegant talk about changing 
trends in the philosophy of supporting science, 
from the very controlled, planned science of put- 
ting a man on the moon, all the way to letting a 
thousand flowers bloom. And they let the thou- 
sand flowers bloom, right? It was the good old 
days, and everything had to be mission-focused. 
An older-looking man raised his hand and said, 
"Don't get your hopes up. I was President 
Eisenhower's science adviser. He wanted to put 
a man on the moon, too." 



Closing Remarks 175 



CONFERENCE SPEAKERS 



Gilbert J. Botvin, Ph.D. 
Professor and Director 
Institute for Prevention Research 
Cornell University Medical College 
411 East 69th Street 
New York, NY 10021 
Tel: 212-746-1270 
Fax: 212-746-8390 

James E. Copple 

Director 

Coalition, State, and Field Services 

National Crime Prevention Council 

1700 K Street, NW, Second Floor 

Washington, DC 20006-3817 

Tel: 202-466-6272x115 

Fax: 202-296-1356 

Thomas J. Dishion, Ph.D. 

Research Scientist 

Oregon Social Learning Center, Inc. 

207 East 5th Avenue, Suite 202 

Eugene, OR 97401 

Tel: 541-346-1983 

Fax: 541-346-4858 

William B. Hansen, Ph.D. 

President 

Tanglewood Research, Inc. 

P.O. Box 1772 

Clemmons, NC 27012 

Tel/Fax: 910-766-3940 



Elaine M. Johnson, Ph.D. 

Director (Retired) 

Center for Substance Abuse Prevention 

663 1 Hunters Wood Circle 

Baltimore, MD 21228 

Tel: 410-744-0086 

Alan I. Leshner, Ph.D. 

Director 

National Institute on Drug Abuse 

5600 Fishers Lane, Room 10-05 

Rockville, MD 20857 

Tel: 301-443-6480 

Fax: 301-443-9127 

General Barry R. McCaffrey 

Director 

Office of National Drug Control Policy 

Executive Office of the President 

Washington, DC 20503 

Tel: 202-395-6700 

Fax: 202-395-6708 

Robert J. Pandina, Ph.D. 
Professor of Psychology and 

Director, Center of Alcohol Studies 
Rutgers University 
607 Allison Road 
Piscataway. NJ 08854-8001 
Tel: 732-445-2686 or 445-25 1 8 
Fax: 732-445-3500 



Conference Speakers 177 



Mary Ann Pentz, Ph.D. 

Associate Professor of Preventive Medicine 

Director 

Center for Prevention Policy Research 

University of Southern California 

1441 Eastlake Avenue, MS-44 

Los Angeles, CA 90033-0800 

Tel: 323-865-0327 

Fax: 323-865-0134 

Gloria M. Rodriguez, D.S.W. 

Project Manager 

State Needs Assessment Project 

New Jersey Department of Health 

153 Halsey Street 

Newark, NJ 07101 

Tel: 973-648-7500 

Fax: 973-648-7384 

Donna E. Shalala, Ph.D. 

Secretary 

U.S. Department of Health and 

Human Services 
200 Independence Avenue, SW 
Washington, DC 20201 
Tel: 202-690-7000 
Fax: 202-690-7203 



Invited Papers 

Leona L. Eggert, Ph.D., R.N. 
Reconnecting At-Risk Youth Prevention 

Research Program 
Psychosocial and Community Health 

Department, School of Nursing 
University of Washington 
Box 357263 

Seattle, WA 98195-7263 
Tel: 206-543-9455 
Fax: 206-685-9551 

Karol L. Kumpfer, Ph.D. 

Director 

Center for Substance Abuse Prevention 

Substance Abuse and Mental Health 

Services Administration 
Rockwall II, Ninth Floor 
5600 Fishers Lane 
Rockville,MD 20857 
Tel: 301-443-0365 
Fax: 301-443-5447 



178 National Conference on Drug Abuse Prevention Research 



PANEL AND WORK GROUP PARTICIPANTS 



Kathryn M. Akerlund, Ed.D. 

Prevention Services Supervisor 

Colorado Alcohol and Drug Abuse Division 

4055 South Lowell Boulevard 

Denver, CO 80236 

Tel: 303-866-7503 

Fax: 303-866-7481 

Rebecca S. Ashery, D.S.W. 

Deputy Director 

Secretary's Initiative on Youth Substance 

Abuse Prevention 
Center for Substance Abuse Prevention 
Division of Epidemiology 
Substance Abuse and Mental Health 

Services Administration 
Rockwall II, Room 140 
5600 Fishers Lane 
Rockville,MD 20857 
Tel: 301-443-1845 
Fax: 301-443-7072 

Ann Blanken 

Deputy Director 

Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A-53 
Rockville, MD 20857 
Tel: 301-443-6504 
Fax: 301-443-2636 



Biddy Bostic 

Acting Prevention Coordinator 

West Virginia Division on Alcoholism 

and Drug Abuse 
State Capitol Complex 
Building 6, Room 738 
Charleston, WV 25305 
Tel: 304-558-2276 
Fax: 304-558-1008 

Susan D. Bridges, Ph.D. 

Psychologist 

Strengthening Families Program 

Bridges to Recovery, Inc. 

1991 West Seven Mile Road 

Detroit, MI 48203 

Tel/Fax: 313-861-3719 (H) or 

Fax: 313-895-0525(0) 

William Bukoski, Ph.D. 
Associate Director for Prevention 

Research Coordination 
Office of the Director 
Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A-53 
Rockville, MD 20857 
Tel: 301-443-2974 
Fax: 301-443-2636 



Panel and Work Group Participants 179 



James D. Colliver, Ph.D. 

Statistician 

Epidemiology Research Branch 

Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A-53 
Rockville,MD 20857 
Tel: 301-443-6637 
Fax: 301-443-2636 



Susan L. David, M.P.H. 
Epidemiology and Prevention 

Research Coordinator 
Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A-53 
Rockville, MD 20857 
Tel: 301-443-6543 
Fax: 301-443-2636 



Thomas J. Connelly 

President 

Safe Schools Institute 

New York State Education Department 

119 Sunset Drive-Balmville 

Newburgh,NY 12550 

Tel: 914-561-2446 

Fax: 914-561-5790 

Leslie Cooper, Ph.D. 
Nurse Epidemiologist 
Epidemiology Research Branch 
Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A-53 
Rockville, MD 20857 
Tel: 301-443-6637 
Fax: 301-443-2636 

Susan L. Coyle, Ph.D. 

Chief 

Clinical, Epidemiological, and Applied 

Sciences Review Branch 
Office of Extramural Program Review 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 10-42 
Rockville, MD 20857 
Tel: 301-443-2620 
Fax: 301-443-0538 

William F. Crimi 

Executive Director 

Franklin County Prevention Institute 

520 East Rich Street 

Columbus, OH 43215 

Tel: 614-224-8822 

Fax: 614-24-8833 



Victoria M. Duran, M.S.W. 

Program Director 

The National PTA 

330 North Wabash Avenue, Suite 2100 

Chicago, IL 60611 

Tel: 312-670-6782 

Fax: 312-670-6783 

Lynn Evans 

Prevention Coordinator 

West Virginia Division on Alcoholism 

and Drug Abuse 
Box 8533 

South Charleston, WV 25303 
Tel/Fax: 304-768-9295 

Meyer Glantz, Ph.D. 
Associate Director for Sciences 
Office of the Director 
Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A-53 
Rockville, MD 20857 
Tel: 301-443-2974 
Fax: 301-443-2636 

Barbara Groves 

State Coordinator-Oregon Together 

Oregon Office of Alcohol and 

Drug Abuse Programs 
500 Summer Street, NE 
Salem, OR 97310 
Tel: 503-945-5764 
Fax: 503-378-8467 



180 National Conference on Drug Abuse Prevention Research 



Jodi Haupt 

Program Coordinator 

Missouri Division of Alcohol and Drug Abuse 

1706 East Elm 

Jefferson City, MO 65101 

Tel: 573-751-4942 

Fax: 573-751-7814 

Mary A. Jansen, Ph.D. 

Director 

Division of Knowledge Development 

and Evaluation 
Center for Substance Abuse Prevention 
Substance Abuse and Mental Health 

Services Administration 
Rockwall II, Ninth Floor 
5600 Fishers Lane 
Rockville, MD 20857 
Tel: 301-654-3536 
Fax: 301-443-8965 

Elizabeth Lambert, M.Sc. 
Health Statistician 
Community Research Branch 
Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A-4 
Rockville, MD 20857 
Tel: 301-443-6720 
Fax: 301-480-4544 

Arnold R. Mills, M.S.W. 
Public Health Advisor 
Community Research Branch 
Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A 
Rockville, MD 20857 
Tel: 301-443-6720 
Fax: 301-480-4544 

Harry Montoya 

President and Chief Executive Officer 

Hands Across Cultures 

P.O. Box 2215 

Route 1, Box 204 

Espanola,NM 87532 

Tel: 505-747-1889 

Fax: 505-747-1623 



Richard Needle, Ph.D., M.P.H. 

Chief 

Community Research Branch 

Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A-42 
Rockville, MD 20857 
Tel: 301-443-6720 
Fax: 301-443-2636 

Ro Nemeth-Coslett, Ph.D. 

Psychologist 

Prevention Research Branch 

Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A-53 
Rockville, MD 20857 
Tel: 301-443-1514 
Fax: 301-443-2636 

Elizabeth Robertson, Ph.D. 
Team Leader 

Prevention Research Branch 
Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A 
Rockville, MD 20857 
Tel: 301-443-1514 
Fax: 301-443-2636 

Phil Salzman 

Director 

Prevention and Community Service 

Health and Education Services 

131 Rantoul Street 

Beverly, MA 01915 

Larry Seitz, Ph.D. 
Program Official 
Prevention Research Branch 
Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A-53 
Rockville, MD 20857 
Tel: 301-443-1514 
Fax: 301-443-2636 



Panel and Work Group Participants 181 



Betty S. Sembler 
Board Member 
Operation PAR 
10324 Paradise Boulevard 
Treasure Island, FL 33706 
Tel: 813-367-1609 
Fax: 813-363-1207 



Carol N. Stone 

Executive Director 

Regional Drug Initiative 

522 SW Fifth Avenue, Suite 1310 

Portland, OR 97204 

Tel: 503-294-7074 

Fax: 503-294-7044 



W. Cecil Short 

President-Elect 

National Association of Secondary 

School Principals 
William Wirt Middle School 
62nd Place and Tuckerman Street 
Riverdale,MD 20737-1499 
Tel: 301-985-1720 
Fax: 301-985-1440 

Zili Sloboda, Sc.D. 

Director 

Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A-53 
Rockville,MD 20857 
Tel: 301-443-6504 
Fax: 301-443-2636 



Naimah Weinberg, M.D. 
Medical Officer 
Epidemiology Research Branch 
Division of Epidemiology and 

Prevention Research 
National Institute on Drug Abuse 
5600 Fishers Lane, Room 9A-53 
Rockville,MD 20857 
Tel: 301-443-6637 
Fax: 301-443-2636 

Sherry T. Young 
Prevention Coordinator 
National Prevention Network 
Utah Division of Substance Abuse 
120 North 200 West, Second Floor 
Salt Lake City, UT 84103 
Tel: 801-538-3939 
Fax: 801-538-4696 



* U.S. GOVERNMENT PRINTING OFFICE: 1998 - 432-978/98274 



182 National Conference on Drug Abuse Prevention Research 



\^r Amazing Research. 
Amazing Help. 



http://nihlibrary.nih.gov 




1 Center Drive 

Bethesda, MD 20892-1150 

301-496-1080 



3 1496 00749 2690 



NIDA 



NATIONAL INSTITUTE 
ON DRUG ABUSE 

NIH Publication No. 98-4293 
September 1 998