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. Copple2
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.
References
Anthony, E.J., and Cohler, B.J., eds. The Invul-
nerable Child. New York: Guilford Press,
1987.
Baron, R.M., and Kenny, D.A. The moderator-
mediator variable distinction in social psycho-
logical research: Conceptual, strategic, and
statistical considerations. J Pers Soc Psychol
51(6):1173-1182, 1986.
Botvin, G.J.; Baker, E.; Dusenbury, L.D.; Botvin,
E.M.; and Diaz, T Long-term followup re-
sults of a randomized drug abuse prevention
trial in a white middle-class population. JAMA
273(14):1106-1112, 1995.
Brook, J.; Balka, E.B.; Abernathy, T; and Ham-
burg, B.A. Sequences of sexual behavior in
African-American and Puerto Rican adoles-
cents. J Genet Psychol 155(1):5-13, 1994.
Brook, J.S.; Cohen, P.; Whiteman, M.; and Gor-
don, A.S. Psychosocial risk factors in the tran-
sition from moderate to heavy use or abuse
of drugs. In: Glantz, M.D., and Pickens, R.,
eds. Vulnerability to Drug Abuse. Washing-
ton, DC: American Psychological Associa-
tion, 1992.
Brook, J.S.; Hamburg, B.A.; Balka, E.B.; and
Wynn, PS. Sequences of drug involvement
in African-American and Puerto Rican ado-
lescents. Psychol Rep 71:179-182, 1992.
Brook, J.S.; Nomura, C; and Cohen, P. A net-
work of influences on adolescent drug in-
volvement: Neighborhood, school, peer, and
family. Genet Soc Gen Psychol Monogr 115:
125-145, 1989.
Brook, J.S.; Whiteman, M.; Balka, E.B.; Win,
P.T.; and Gursen, M.D. African- American and
Puerto Rican drug use: A longitudinal study.
J Am Acad Child Adolesc Psychiatry,
36(9): 1260- 1268, 1997.
Brook, J.S.; Whiteman, M.; Hamburg, B.A.; and
Balka, E.B. African- American and Puerto
Rican drug use: Personality, familial, and
other environmental risk factors. Genet Soc
Gen Psychol Monogr US (4):417-438, 1992.
Bry, B. Predicting drug abuse: Review and re-
formulation. Int J Addict 18:223-233, 1983.
Risk and Protective Factor Models in Adolescent Drug Use 23
Bry, B., and Krinsley, K. Adolescent substance
abuse. In: Feindler, E., and Kalfus, G., eds.
Adolescent Behavior Therapy Handbook.
New York: Springer Publishing Company,
1990.
Bry, B.H.; McKeon, P.; and Pandina, R.J. Extent
of drug use as a function of number of risk
factors. J Abnorm Psychol 91:273-279, 1982.
Bry, B.; Pedraza, M.; and Pandina, R. Number
of risk factors predicts 3-year probabilities of
heavy drug and alcohol use in adolescents.
In: Harris, L.S., ed. Problems of Drug De-
pendence 1987: Proceedings of the 49th An-
nual Scientific Meeting, The Committee on
Problems of Drug Dependence, Inc. National
Institute on Drug Abuse Research Monograph
81. DHHS Pub No. (ADM)88-1564. Wash-
ington, DC: Supt. of Docs., U.S. Govt. Print.
Off., 1988.
Clayton, R. Transitions in drug use: Risk and
protective factors. In: Glantz, M., and Pickens,
R., eds. Vulnerability to Drug Abuse. Wash-
ington, DC: American Psychological Associa-
tion, 1992.
Coie, J.D.; Watt, N.F.; West, S.G.; Hawkins, J.D.;
Asarnow, J.R.; Markman, H.J.; Ramey, S.L.;
Shure, M.B.; and Long, B. The science of pre-
vention. A conceptual framework and some
directions for a national research program. Am
Psychol 48(10):1013-1022, 1993.
Compas, B.E.: Hinden, B.R.; and Gerhardt, C.A.
Adolescent development: Pathways and pro-
cesses of risk and resilience. In: Spence, J.T.;
Darley, J.M.; and Foss, D.J., eds. Annual Re-
view of Psychology, Volume 46. Palo Alto,
CA: Annual Reviews Inc., 1995.
Dishion, T.J.; Kavanagh, K.; and Kiesner, J. Pre-
vention of early substance use among high-
risk youth: A multiple gating approach to
parent intervention. In: Ashery, R.; Kumpfer,
K.L.; and Robertson, E., eds. Drug Preven-
tion Through Family Interventions. National
Institute on Drug Abuse Research Mono-
graph 177. U.S. Department of Health and
Human Services, National Institutes of
Health, National Insitute on Drug Abuse, in
press.
Donaldson, S.I.; Graham, J.W; and Hansen, WB.
Testing the generalizability of intervening
mechanism theories: Understanding the ef-
fects of adolescent drug use prevention inter-
ventions. J Behav Med 17(2): 195-216, 1994.
Eggert, L.L.; Seyl, CD.; and Nicholas, L.J. Ef-
fects of a school-based prevention program
for potential high school dropouts and drug
abusers. Int J Addict 25(7):773-801, 1990.
Ford, D.H. Humans as Self-Constructing Living
Systems: A Developmental Perspective on Be-
havior and Personality. Hillside, NJ:
Lawrence Erlbaum Associates, 1987.
Gable, R.S. Toward a comparative overview of
dependence potential and acute toxicity of
psychoactive substances used nonmedically.
Am J Drug Alcohol Abuse 19(3):263-281,
1993.
Garmezy, N., and Masten, A.S. Chronic adver-
sities. In: Rutter, M.; Taylor, E; and Hersov,
L., eds. Child and Adolescent Psychiatry.
Boston: Blackwell Scientific Publications,
1994.
Glantz, M., and Pickens, R., eds. Vulnerability
to Drug Abuse. Washington, DC: American
Psychological Association, 1992.
Hancock, M. Prediction of Problem Behavior in
Adolescence: The Impact of Stability and
Change in the Number of Risk and Protec-
tive Factors. Doctoral dissertation, Depart-
ment of Psychology. New Brunswick, NJ:
Rutgers University, 1996.
Hawkins, J.D.; Catalano, R.F.; and Miller, J.Y.
Risk and protective factors for alcohol and
other drug problems in adolescence and early
adulthood: Implications for substance abuse
prevention. Psychol Bull 112(1):64-105,
1992.
Jessor, R. Successful adolescent development
among youth in high-risk settings. Am Psychol
48(2):117-126, 1993.
Kandel, D. Stages in adolescent involvement in
drug use. Science 190:912-914, 1975.
Kandel, D.B. Drug and drinking behavior among
youth. Ann Rev Sociol 6:235-285, 1980.
24 National Conference on Drug Abuse Prevention Research
Kandel, D.B.; Yamaguchi, K.; and Chen, K.
Stages of progression in drug involvement
from adolescence to adulthood: Further evi-
dence for the gateway theory. J Stud Alcohol
53:447-457, 1992.
Kannel, W., and Schatzkin, A. Risk factor analy-
sis. Prog Cardiovasc Dis 26:309-332, 1983.
Kumpfer, K.L.; Molgaard, V.; and Spoth, R. The
"Strengthening Families Program" for the
prevention of delinquency and drug use. In:
Peters, R.D., and McMahon, R.J., eds. Pre-
venting Childhood Disorders, Substance
Abuse, and Delinquency. Newbury Park, CA:
Sage Publications, 1996.
Labouvie, E.; Bates, M.E.; and Pandina, R.J. Age
of first use: Its reliability and predictive util-
ity. J Stud Alcohol 58(6):638-643, 1997.
Labouvie, E.; Pandina, R.J.; and Johnson, V.
Developmental trajectories of substance use
in adolescence: Differences and predictors. Int
JBehavDev 14(3):305-328, 1991.
Lettieri, D.J.; Sayers, M.; and Pearson, H.W., eds.
Theories on Drug Abuse: Selected Contem-
porary Perspectives. National Institute on
Drug Abuse Research Monograph 30. DHHS
Pub. No. (ADM)83-967. Washington, DC:
Supt. of Docs., U.S. Govt. Print. Off., 1983.
488 pp.
Miller, J.G. Living Systems. New York: McGraw-
Hill, 1978.
Mrazek, P.J., and Haggerty, R.J., eds. Reducing
the Risk for Mental Disorders: Frontiers for
Preventive Intervention Research. Washing-
ton, DC: National Academy Press for the In-
stitute of Medicine, Committee on Prevention
of Mental Disorders, 1994.
Munoz, R.F.; Mrazek, P.J.; and Haggerty, R.J.
Institute of Medicine report on prevention of
mental disorders: Summary and commentary.
Am/Vc/jo/51(ll):1116-1122, 1996.
Newcomb, M.D. Identifying high-risk youth:
Prevalence and patterns of adolescent drug
abuse. In: Rahdert, E., and Chzechowicz, D.,
eds. Adolescent Drug Abuse: Clinical Assess-
ment and Therapeutic Interventions. National
Institute on Drug Abuse Research Monograph
156. DHHS Pub. No. 95-3908. U.S. Depart-
ment of Health and Human Services, National
Institutes of Health, National Institute on Drug
Abuse, 1995.
Newcomb, M.D., and Felix-Ortiz, M. Multiple
protective and risk factors for drug use and
abuse: Cross-sectional and prospective find-
ings. JPers Soc Psychol 63(2):280-296, 1992.
Newcomb, M.D.; Maddahian, E.; and Bentler,
P.M. Risk factors for drug use among adoles-
cents: Concurrent and longitudinal analyses.
Am J Public Health 76:525-531, 1986.
Pandina, R.J.; Johnson, V.; and Labouvie, E.W.
Affectivity: A central mechanism in the de-
velopment of drug dependence. In: Glantz,
M., and Pickens, R., eds. Vulnerability to
Drug Abuse. Washington, DC: American Psy-
chological Association, 1992.
Pentz, M.A.; Dwyer, J.H.; MacKinnon, D.P.;
Flay, B.R.; Hansen, W.B.; Wang, E.Y; and
Johnson, C.A. A multicommunity trial for pri-
mary prevention of adolescent drug abuse: Ef-
fects on drug use prevalence. JAMA
261(22):3259-3266, 1989.
Petraitis, J.; Flay, B.R.; and Miller, T.Q. Review-
ing theories of adolescent substance use: Or-
ganizing pieces in the puzzle. Psychol Bull
117(l):67-86, 1995.
Piazza, P.V., and LeMoal, M. Pathophysiologi-
cal basis of vulnerability to drug abuse: Role
of an interaction between stress, glucocorti-
coids, and dopaminergic neurons. Ann Rev
Pharmacol Toxicol 36:359-378, 1996.
Reiss, D., and Price, R.H. National Research
Agenda for Prevention Research: The Na-
tional Institute of Mental Health Report. Am
Psychol 5\(U):l 109-1115, 1996.
Rogosch, F; Chassin, L.; and Sher, K.J. Person-
ality variables as mediators and moderators
of family history risk for alcoholism: Con-
ceptual and methodological issues. J Stud
Alcohol 51(4): 310-318, 1990.
Risk and Protective Factor Models in Adolescent Drug Use 25
Rothman, K.J. Modern Epidemiology. Boston:
Little, Brown and Company, 1986.
Rutter, M. Resilience in the face of adversity:
Protective factors in resistance to psychiatric
disorders. Br J Psychiatry 147:598-611, 1985.
Scheier, L.M., and Newcomb, M.D. Psychoso-
cial predictors of drug use initiation and es-
calation: An expansion of the multiple risk
factors hypothesis using longitudinal data.
Contemp Drug Prob, Special Reprint, 1991.
Tobler, N.S. Drug prevention programs can work:
Research findings. J Addict Dis 11(3): 1-28,
1992.
Wise, R.A. Addictive drugs and brain stimula-
tion reward. Ann Rev Neurosci 19:319-340,
1996.
Yamaguchi, K., and Kandel, D.B. Patterns of
drug use from adolescence to young adult-
hood: II. Sequences of progression. Am J
Public Health 74:668-672, 1984.
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
5V2 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.
References
Ajzen, I., and Fishbein, M. Understanding Atti-
tudes and Predicting Social Behavior.
Englewood Cliffs, NJ: Prentice-Hall, 1980.
Bandura, A. Social Learning Theory. Englewood
Cliffs, NJ: Prentice-Hall, 1977.
Bangert-Drowns, R.L. The effects of school-
based substance abuse education: A meta-
analysis. J Drug Educ 18:243-264, 1988.
Basen-Enquist, K.; O'Hara-Tompkins, N.;
Lovato, C.Y.; Lewis, M.J.; Parcel, G.S.; and
Gingiss, P. The effects of two types of teacher
training on implementation of Smart Choices:
A tobacco prevention curriculum. J Sch
Health 64(8):334-339, 1994.
Becker, M.H. The health belief model and per-
sonal health behavior. Health Educ Monogr
2: 324-473, 1974.
Bernstein, D.A., and McAlister, A. The modifi-
cation of smoking behavior: An evaluative re-
view. Psychol Bull 71: 418-440, 1969.
Best, J.A.; Thomson, S.J.; Santi, S.M.; Smith,
E.A.; and Brown, K.S. Preventing cigarette
smoking among schoolchildren. Ann Rev
Public Health 9:161-201, 1988.
Bosworth, K., and Sailes, J. Content and teach-
ing strategies in 10 selected drug abuse pre-
vention curricula. J Sch Health 63(6):
247-253, 1993.
Botvin, G.J.; Baker, E.; Dusenbury, L.; Tortu, S.;
and Botvin, E.M. Preventing adolescent
drug abuse through a multimodal cognitive-
behavioral approach: Results of a 3-year
study. / Consult Clin Psychol 58(4):437-446,
1990.
38 National Conference on Drug Abuse Prevention Research
Botvin, G.J., and Wills, T.S. Personal and social
skills training: Cognitive-behavioral ap-
proaches to substance abuse prevention. In:
Bell, C, and Battjes, R., eds. Prevention Re-
search: Deterring Drug Abuse Among Chil-
dren and Adolescents. National Institute on
Drug Abuse Research Monograph 63. DHHS
Pub. No. (ADM)87-1334. Washington, DC:
Supt. of Docs., U.S. Govt. Print. Off., 1987;
Reprinted 1989.
Coie, J.D.; Watt, N.F.; West, S.G.; Hawkins, J.D.;
Asarnow, J.R.; Markman, H.J.; Ramey, S.L.;
Shure, M.B.; and Long, B. The science of pre-
vention. A conceptual framework and some
directions for a national research program. Am
Psychol 48(10): 1013-1022, 1993.
Donaldson, S.I.; Graham, J.W.; and Hansen, W.B.
Testing the generalizability of intervening
mechanism theories: Understanding the ef-
fects of adolescent drug use prevention inter-
ventions. JBehavMed 17(2): 195-216, 1994.
Dusenbury, L., and Falco, M. Eleven components
of effective drug abuse prevention curricula.
J Sch Health 65:420-425, 1995.
Edwards, R.W. Drug use among eighth-grade
students is increasing. Int J Addict 28(4): 1621-
1623, 1993.
Ennett, S.T.; Ringwalt, C; and Flewelling, R.L.
How effective is Drug Abuse Resistance Edu-
cation? A meta-analysis of Project DARE
evaluations. Am J Public Health 84(9): 1 394-
1401. 1994.
Evans, R.I., and Raines, B.E. Control and pre-
vention of smoking in adolescents: A psycho-
logical perspective. In: Coates,T.J.; Petersen,
A.C.; and Perry, C, eds. Promoting Adoles-
cent Health. New York: Academic Press,
1982.
Evans, R.L; Rozelle, R.M.; Mittelmark, M.B.;
Hansen, W.B.; Bane, A.L.; and Ha vis, J. De-
terring the onset of smoking in children:
Knowledge of immediate physiological ef-
fects and coping with peer pressure, media
pressure, and parent modeling. J Appl Soc
Psychol S(2):126-135, 1978.
Falco, M. Making the Grade: A Guide to School
Drug Prevention Programs. Washington, DC:
Drug Strategies, 1996.
Flannery, D.J., and Torquati, J. An elementary
school substance abuse prevention program:
Teacher and administrator perspectives.
J Drug Educ 23(4):3%7 -391, 1993.
Flay, B.R. Psychosocial approaches to smoking
prevention: A review of findings. Health
Psychol 4(5):449-488, 1985.
Gingiss, PL. Enhancing program implementa-
tion and maintenance through a multiphase
approach to peer-based staff development.
J Sch Health 62(5): 161- 166, 1992.
Gingiss, PL.; Gottlieb, N.H.; and Brink, S.G.
Increasing teacher receptivity toward use of
tobacco prevention education programs.
J Drug Educ 24(2): 163- 176, 1994.
Goodstadt, M.S. Drug education: A turn-on or a
turn-off? J Drug Educ 10:89-99, 1980.
Gordon, N.P., and McAlister, A.L. Adolescent
Drinking: Issues and Research. New York:
Academic Press, 1982.
Graham, J.W.; Collins, L.M.; Wugalter, S.E.;
Chung, N.K.; and Hansen, W.B. Modeling
transitions in latent stage-sequential pro-
cesses: A substance abuse use prevention ex-
ample. J Consult Clin Psychol 59(l):48-57,
1991.
Hansen, W.B. School-based substance abuse pre-
vention: A review of the state of the art in
curriculum, 1980-1990. Health Educ Res
7(3):403-430, 1992.
Hansen, W.B. Aproximaciones psicosociales a
la prevention: El uso de las investigaciones
epidemiologicas y etiologicas para el
desarrollo de intervenciones efectivas. (Psy-
chosocial approaches to prevention: Using
epidemiology and etiology research to de-
velop strategies to develop effective inter-
ventions.) Psicol Conductual 3(3):357-378,
1996a.
Prevention Programs: Critical Factors 39
Hansen, W.B. Pilot-test results comparing the All
Stars program with seventh-grade DARE:
Program integrity and mediating variable
analysis. Subst Use Misuse 31(10):1359-1377,
1996&.
Hansen, W.B., and Graham, J.W. Preventing al-
cohol, marijuana, and cigarette use among
adolescents: Peer pressure resistance training
versus establishing conservative norms. Prev
Med 20:414-430, 1991.
Hansen, W.B., and Graham, J.W. "Comparison
of Postulated Mediators of School-Based Sub-
stance Use Prevention in Adolescents: A Lon-
gitudinal Examination." Unpublished
manuscript.
Hansen, W.B.; Graham, J.W.; Wolkenstein, B.H.;
Lundy, B.Z.; Pearson, J.L.; Flay, B.R.; and
Johnson, C.A. Differential impact of three al-
cohol prevention curricula on hypothesized
mediating variables. J Drug Educ 18(2): 143-
153, 1988.
Hansen, W.B.; Johnson, C.A.; Flay, B.R.; Gra-
ham, J.W.; and Sobel, J.L. Affective and so-
cial influences approaches to the prevention
of multiple substance abuse among seventh-
grade students: Results from Project SMART.
Prev Med 17:1-20, 1988.
Hansen, W.B., and McNeal, R.B. The law of
maximum expected potential effect: Con-
straints placed on program effectiveness by
mediator relationships. Health Educ Res
ll(4):501-507, 1996.
Hansen, W.B., and McNeal, R.B. How DARE
works: An examination of program effects on
mediating variables. Health Educ Behav
24(2): 165-176, 1997.
Hansen, W.B., and Rose, L.A. Recreational use
of inhalant drugs by adolescents: A challenge
for family physicians. Earn Pract 27(6):383-
387, 1995.
Hansen, W.B.; Rose, L.A.; and Dryfoos, J.G.
"Causal Factors, Interventions and Policy
Considerations in School-Based Substance
Abuse Prevention." Report submitted to the
Office of Technology Assessment, U.S. Con-
gress, 1993.
Higgins, E.T.; Ruble, D.N.; and Hartup, W.W.,
eds. Social Cognition and Social Develop-
ment: A Sociocultural Perspective. New York:
Cambridge University Press, 1983.
Hirschi, T. Causes of Delinquency. Berkeley, CA:
University of California Press, 1969.
Johnston, L.D.; O'Malley, P.M.; and Bachman,
J.G. National Survey Results on Drug Use
From the Monitoring the Future Study, 1975-
1995. Volume I: Secondary School Students.
NIH Pub. No. 96-4139. Rockville, MD: U.S.
Department of Health and Human Services,
National Institutes of Health, National Insti-
tute on Drug Abuse, 1996.
Johnston, L.D.; O'Malley, P.M.; and Bachman,
J.G. National Survey Results on Drug Use
From the Monitoring the Future Study, 1975-
1995. Volume II: College Students and Young
Adults. NIH Pub. No. 96-4139. Rockville,
MD: U.S. Department of Health and Human
Services, National Institutes of Health, Na-
tional Institute on Drug Abuse, 1996.
Kandel, D.B. Convergences in prospective lon-
gitudinal surveys of drug use in normal popu-
lations. In: Kandel, D.B., ed. Longitudinal
Research on Drug Use: Empirical Findings
and Methodological Issues. Washington, DC:
Hemisphere (Halsted- Wiley), 1978.
Kandel, D.B.; Yamaguchi, K.; and Chen, K.
Stages of progression in drug involvement
from adolescence to adulthood: Further evi-
dence for the gateway theory. J Stud Alcohol
53:447-457, 1992.
Kingery, P.M.; Ballard, D.J.; and Bruitt, B.E. The
self-efficacy of school health promoters.
Health Values 14(5):25-33, 1990.
Leventhal, H., and Cleary, PD. The smoking
problem: A review of the research and theory
in behavioral risk modification. Psychol Bull
88(2):370-405, 1980.
MacKinnon, D.P. Analysis of mediating variables
in prevention and intervention research. In:
Cazares, A., and Beatty, L.A., eds. Scientific
Methods for Prevention Intervention Re-
search. National Institute on Drug Abuse
40 National Conference on Drug Abuse Prevention Research
Research Monograph 139. NIH Pub. No. 94-
3631. U.S. Department of Health and Human
Services, National Institutes of Health, Na-
tional Institute on Drug Abuse, 1994.
MacKinnon, D.P., and Dwyer, J.H. Estimating
mediated effects in prevention studies. Eval
Rev 17(2): 144-158, 1993.
MacKinnon, D.P.; Johnson, C.A.; Pentz, M.A.;
Dwyer, J.H.; Hansen, W.B.; Flay, B.R.; and
Wang, E.Y. How school-based drug preven-
tion works: One-year effects of the Midwest-
ern Prevention Project. Health Psychol
10:164-172, 1991.
McNeal, R.B., and Hansen, W.B. An examina-
tion of strategies for gaining convergent va-
lidity in natural experiments: DARE as an
illustrative case study. Eval Rev 19(2): 141-
158, 1995.
Moskowitz, J.M. The primary prevention of al-
cohol problems: A critical review of the re-
search literature. J Stud Alcohol 50(l):54-88,
1989.
Moskowitz, J.M.; Malvin, J.; Schaeffer, G.A.;
and Schaps, E. Evaluation of a junior high
school primary prevention program. Addict
5e/zav8(4):393-401, 1983.
Parcel, G.S.; Ross, J.G.; Lavin, A.T.; Portnoy,
B.; Nelson, G.D.; and Winters F. Enhancing
implementation of the teenage health teach-
ing modules. J Sch Health 6l(l):35-3S, 1991.
Parcel, G.S.; Simons-Morton, B.G.; and Kolbe,
L.J. Health promotion: Integrating organiza-
tional change and student learning strategies.
Health Educ Q 15(4):436-450, 1988.
Paulussen, T.G.W.; Kok, G.J.; and Schaalma,
H.P Antecedents to adoption of classroom-
based AIDS education in secondary schools.
Health Educ Res 9:485-496, 1994.
Pentz, M.A.; MacKinnon, D.P; Dwyer, J.H.;
Wang, E.Y.; Hansen, W.B.; Flay B.R.; and
Johnson, C.A. Longitudinal effects of the
Midwestern Prevention Project on regular and
experimental smoking in adolescents. Prev
Med 18:304-321, 1989.
Perhats, C.; Oh, K.; Levy, S.R.; Flay, B.R.; and
McFall, S. Role differences in gatekeeper per-
ceptions of school-based drug and sexuality
education programs: Across-sectional survey.
Health Educ Res 11(1): 11-27, 1996.
Rohrbach, L.A.; Graham, J.W.; and Hansen, W.B.
Diffusion of a school-based substance abuse
prevention program: Predictors of program
implementation. Prev Med 22:237-260, 1993.
Schaps, E.; DiBartolo, R.; Moskowitz, J.; Palley,
C.; Churgin, S. A review of 127 drug abuse
prevention program evaluations. J Drug Is-
sues 11(1):17 -43, 1981.
Smith, D.W.; McCormick, L.K.; Steckler, A.B.;
and McLeroy, K.R. Teachers' use of health
curricula: Implementation of growing healthy,
project SMART, and the teenage health teach-
ing modules. J Sch Health 63(8):349-354,
1993.
Thompson, E.L. Smoking education programs
1960-1976. Am J Public Health 68(3):250-
257, 1978.
Tobler, N.S. Meta-analysis of 143 adolescent
drug prevention programs: Quantitative out-
come results of program participants com-
pared to a control or comparison group.
J Drug Issues 16:537-567, 1986.
Tobler, N.S., and Stratton, H.H. Effectiveness of
school-based drug prevention programs: A
meta-analysis of the research. J Prim Prev
18(1):71-128, 1997.
Watson, M.; Schaps, E.; Battistich, V.; Solomon,
D.; and Solomon, J. The Child Development
Project: Combining Traditional and Devel-
opmental Approaches to Values Education:
A Dialogue. Berkeley, CA: McCutchan, 1989.
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
References
Arkin, R.M.; Roemhild, H.J.; Johnson, C.A.;
Luepker, R.V.; and Murray, D.M. The Min-
nesota smoking prevention program: A
seventh-grade health curriculum supplement.
J Sch Health 51:616-661, 1981.
Bandura, A. Social Learning Theory. Englewood
Cliffs, NJ: Prentice Hall, 1977.
Bell, R.M.; Ellickson, P.L.; and Harrison, E.R.
Do drug prevention effects persist into high
school? Prev Med 22:463-483.
Bettes, B.A.; Dusenbury, L.; Kerner, J.; James-
Ortiz, S.; and Botvin, G.J. Ethnicity and psy-
chosocial factors in alcohol and tobacco use
in adolescence. Child Dev 61:557-565, 1990.
Botvin, G.J. Substance abuse prevention through
life skills training. In: Peters, R.D., and
McMahon, R.J., eds. Preventing Childhood
Disorders, Substance Abuse, and Delin-
quency. Banff International Behavioral Sci-
ence Series, Vol. 3. Thousand Oaks, CA: Sage
Publications, 1996. pp. 215-240.
Botvin, G.J.; Baker, E.; Botvin, E.M.; Dusenbury,
L.; Cardwell, J.; and Diaz, T. Factors promot-
ing cigarette smoking among black youth: A
causal modeling approach. Addict Behav
18:397-405, 1993.
Botvin, G.J.; Baker, E.; Botvin, E.M.; Filazzola,
A.D.; and Millman, R.B. Alcohol abuse pre-
vention through the development of personal
and social competence: A pilot study. J Stud
Alcohol 45:550-552, 1984.
Botvin, G.J.; Baker, E.; Dusenbury, L.D.; Botvin,
E.M.; and Diaz, T Long-term followup re-
sults of a randomized drug abuse prevention
trial in a white middle-class population. JAMA
273(14):1106-1112, 1995.
Botvin, G.J.; Baker, E.; Dusenbury, L.; Tortu, S.;
and Botvin, E.M. Preventing adolescent
drug abuse through a multimodal cognitive-
behavioral approach: Results of a 3-year
study. J Consult Clin Psychol 58(4):437-446,
1990.
Botvin, G.J.; Baker, E.; Filazzola, A.; and Botvin,
E.M. A cognitive-behavioral approach to sub-
stance abuse prevention: A 1-year followup.
Addict Behav 15:47-63, 1990.
Botvin, G.J.; Baker, E.; Renick, N.L.; Filazzola,
A.D.; and Botvin, E.M. A cognitive-
behavioral approach to substance abuse pre-
vention. Addict Behav 9:137-147, 1984.
Botvin, G.J.; Batson, H.W.; Witts-Vitale, S.;
Bess, V.; Baker, E.; and Dusenbury, L. A psy-
chosocial approach to smoking prevention for
urban black youth. Public Health Rep
104(6):573-582, 1989.
Botvin, G.J., and Botvin, E.M. Adolescent to-
bacco, alcohol, and drug abuse: Prevention
strategies, empirical findings, and assessment
issues. J Dev Behav Pediatr 13:290-301,
1992.
Botvin, G.J., and Cardwell, J. Primary Preven-
tion (Smoking) of Cancer in Black Popula-
tions. National Cancer Institute Contract No.
N01-CN-6508. Final Report to National Can-
cer Institute. Ithaca, NY: Cornell University
Medical College, 1992.
Botvin, G.J.; Dusenbury, L.; Baker, E.; James-
Ortiz, S.; Botvin, E.M.; and Kerner, J. Smok-
ing prevention among urban minority youth:
Assessing effects on outcome and mediating
variables. Health Psychol ll(5):290-299,
1992.
Botvin, G.J.; Dusenbury, L.; Baker, E.; James-
Ortiz, S.; and Kerner, J. A skills training ap-
proach to smoking prevention among
Hispanic youth. J Behav Med 12(3):279-296,
1989.
Botvin, G.J., and Eng, A. A comprehensive
school-based smoking prevention program.
J Sch Health 50:209-213, 1980.
Botvin, G.J., and Eng, A. The efficacy of a mul-
ticomponent approach to the prevention of
cigarette smoking. Prev Med 11:199-211,
1982.
Botvin, G.J.; Eng, A.; and Williams, C.L. Pre-
venting the onset of cigarette smoking through
Life Skills Training. Prev Med 9:135-143,
1980.
Botvin, G.J.; Epstein, J. A.; Schinke, S.P; and
Diaz, T Predictors of cigarette smoking
among inner-city minority youth. Dev Behav
Pediatr 15:67-73, 1994.
Preventing Drug Abuse Through the Schools 53
Botvin, G.J.; Goldberg, C.J.; Botvin, E.M.; and
Dusenbury, L. Smoking behavior of adoles-
cents exposed to cigarette advertising. Pub-
lic Health Rep 108(2):217-224, 1993.
Botvin, G.J.; Renick, N.; and Baker, E. The ef-
fects of scheduling format and booster ses-
sions on a broad-spectrum psychosocial
approach to smoking prevention. JBehav Med
6(4):359-379, 1983.
Botvin, G.J.; Schinke, S.P.; Epstein, J.A.; and
Diaz, T. The effectiveness of culturally fo-
cused and generic skills training approaches
to alcohol and drug abuse prevention among
minority youth. Psychol Addict Behav 8:116-
127,1994.
Botvin, G.J.; Schinke, S.P.; Epstein, J.A.; Diaz,
T; and Botvin, E.M. Effectiveness of cultur-
ally focused and generic skills training ap-
proaches to alcohol and drug abuse prevention
among minority adolescents: Two-year
followup results. Psychol Addict Behav
9(3): 183-194, 1995.
Caplan, M.; Weissberg, R.P.; Grober, J.S.; Sivo,
P.; Grady, K.; and Jacoby, C. Social compe-
tence promotion with inner-city and subur-
ban young adolescents: Effects on social
adjustment and alcohol use. J Consult Clin
Psychol 60(l):56-63, 1992.
Donaldson, S.I.; Graham, J.W.; and Hansen, W.B.
Testing the generalizability of intervening
mechanism theories: Understanding the ef-
fects of adolescent drug use prevention inter-
ventions. J Behav Med 17(2): 195-216, 1994.
Donaldson, S.I.; Graham, J.W.; Piccinin, A.M.;
and Hansen, W.B. Resistance skills training
and onset of alcohol use: Evidence for ben-
eficial and potentially harmful effects in pub-
lic schools and in private Catholic schools.
Health Psychol 14(4):291-300, 1995.
Dorn, N., and Thompson, A. Evaluation of drug
education in the longer term is not an optional
extra. Community Health 7:154-161, 1976.
Dryfoos, J.G. Common components of success-
ful interventions with high-risk youth. In:
Bell, N.J., and Bell, R.W., eds. Adolescent
Risk Taking. Newbury Park, CA: Sage Publi-
cations, 1993.
Ellickson, PL., and Bell, R.M. Prospects for
Preventing Drug Abuse Among Young Ado-
lescents. Rand Publication Series, 1990.
Ellickson, PL.; Bell, R.M.; and McGuigan, K.
Preventing adolescent drug use: Long-term
results of a junior high program. Am J Public
Health 83:856-861, 1993.
Ennett, S.T.; Tobler, N.S.; Ringwalt, C.L.; and
Flewelling, R.L. How effective is drug abuse
resistance education? A meta-analysis of
Project DARE outcome evaluations. Am J
Public Health 84:1394-1401, 1994.
Epstein, J. A.; Botvin, G.J.; Diaz, T; and Schinke,
S.P The role of social factors and individual
characteristics in promoting alcohol among
inner-city minority youth. J Stud Alcohol
56(l):39-46, 1995.
Epstein, J. A.; Botvin, G.J.; Diaz, T; Toth, V.; and
Schinke, S.P. Social and personal factors in
marijuana use and intentions to use drugs
among inner-city minority youth. JDev Behav
Pediatr 16(1): 14-20, 1995.
Epstein, J.A.; Dusenbury, L.; Botvin, G.J.; and
Diaz, T Determinants of intentions of junior
high school students to become sexually ac-
tive and use condoms: Implications for reduc-
tion and prevention of AIDS risk. Psychol Rep
75:1043-1053, 1994.
Evans, R.I. Smoking in children: Developing a
social psychological strategy of deterrence.
PrevMed 5:122-127, 1976.
Evans, R.I.; Rozelle, R.M.; Mittelmark, M.B.;
Hansen, W.B.; Bane, A.L.; and Havis, J. De-
terring the onset of smoking in children:
Knowledge of immediate physiological ef-
fects and coping with peer pressure, media
pressure, and parent modeling. J Appl Soc
Psychol 8(2): 126-135, 1978.
Fishbein, M. Consumer beliefs and behavior with
respect to cigarette smoking: A critical analy-
sis of the public literature. In: Federal Trade
Commission Report to Congress Pursuant to
the Public Health Cigarette Smoking Act of
1976. Washington, DC: Supt. of Docs., U.S.
Govt. Print. Off., 1977.
54 National Conference on Drug Abuse Prevention Research
Fisher, D.A.; Armstrong, B.K.; and deKler, N.H.
"A Randomized Controlled Trial of Educa-
tion for Prevention of Smoking in 12- Year-
Old Children." Paper presented at the Fifth
World Conference on Smoking and Health,
Winnipeg, Canada, 1983.
Flay, B.R.; Keopke, D.; Thomson, S.J.; Sand, S.;
Best, J. A.; and Brown, K.S. Long-term
followup of the first Waterloo smoking pre-
vention trial. Am J Public Health 79(10):
1371-1376, 1989.
Flynn, B.S.; Worden, J.K.; Seeker- Walker, R.H.;
Badger, G.J.; Geller, B.M.; and Costanza,
M.C. Prevention of cigarette smoking through
mass media intervention and school programs.
Am J Public Health 82(6):827-834, 1992.
Gilchrist, L.D., and Schinke, S.P Self-control
skills for smoking prevention. In: Engstrom,
P.F.; Anderson, P.; and Mortenson, L.E., eds.
Advances in Cancer Control. New York: Alan
R. Liss, 1983.
Goodstadt, M.S. Myths and methodology in drug
education: A critical review of the research
evidence. In: Goodstadt, M., ed. Research on
Methods and Programs of Drug Education.
Toronto: International Council on Alcohol and
Addictions, 1974.
Hamburg, B.A.; Kraemer, H.C.; and Jahnke, W.
A hierarchy of drug use in adolescence: Be-
havioral and attitudinal correlates of substan-
tial drug use. Am J Psychiatry 132(11):
1155-1163, 1975.
Hansen, W.B. and O'Malley, P.M. Drug use. In:
DiClemente, R.J.; Hansen, W.B.; and Ponton,
L.E., eds. Handbook of Adolescent Health
Risk Behavior: Issues in Clinical Child Psy-
chology. New York: Plenum Press, 1966.
Hurd, P.; Johnson, C.A.; Pechacek, T; Bast, C.P.;
Jacobs, D.; and Luepker, R. Prevention of
cigarette smoking in seventh-grade students.
J Behav Med 3-.15-2S, 1980.
Jessor, R., and Jessor, S.L. Problem Behavior and
Psychosocial Development: A Longitudinal
Study of Youth. New York: Academic Press,
1977. '
Kandel, D.B. Convergences in prospective lon-
gitudinal surveys of drug use in normal popu-
lations. In: Kandel, D.B., ed. Longitudinal
Research on Drug Use: Empirical Findings
and Methodological Issues. Washington, DC:
Hemisphere (Halsted- Wiley), 1978.
Kearney, A.L., and Hines, M.H. Evaluation of
the effectiveness of a drug prevention educa-
tion program. J Drug Educ 10:127-134, 1980.
Kim, S. A short- and long-term evaluation of
"Here's Looking at You" II. J Drug Educ
18:235-242, 1988.
Kinder, B.N.; Pape, N.E.; and Walfish, S. Drug
and alcohol education programs: A review of
outcome studies. Int J Addict 15:1035-1054,
1980.
Kreutter, K.J.; Gewirtz, H.; Davenny, J.E.; and
Love, C. Drug and alcohol prevention project
for sixth graders: First-year findings. Adoles-
cence 26(102):287 '-292, 1991.
Luepker, R.V.; Johnson, C.A.; Murray, D.M.; and
Pechacek, T.F. Prevention of cigarette smok-
ing: Three-year followup of educational pro-
grams for youth. J Behav Med 6:53-61, 1983.
McAlister, A.; Perry, C.L.; Killen, J.; Slinkard,
L.A.; and Maccoby, N. Pilot study of smok-
ing, alcohol, and drug abuse prevention. Am
J Public Health 70:719-721, 1980.
McAlister, A.; Perry, C; and Maccoby, N. Ado-
lescent smoking: Onset and prevention. Pe-
diatrics 63:650-658, 1979.
McGuire, W.J. Inducing resistance to persuasion:
Some contemporary approaches. In: Berk-
owitz, L., ed. Advances in Experimental
Social Psychology. New York: Academic
Press, 1964.
McGuire, W.J. The nature of attitudes and atti-
tude change. In: Lindzey, G., and Aronson,
E., eds. Handbook of Social Psychology.
Reading, MA: Addison-Wesley, 1968.
Preventing Drug Abuse Through the Schools 55
Murray, D.M.; Davis-Hearn, M.: Goldman, A.I.;
Pirie, P.; and Luepker, R.V. Four- and five-
year followup results from four seventh-grade
smoking prevention strategies. J Behav Med
ll(4):395-405, 1988.
Pentz, M.A. Prevention of adolescent substance
abuse through social skill development. In:
Glynn, T.J.; Leukefeld, C.G.; and Ludford,
J.B., eds. Preventing Adolescent Drug Abuse:
Intervention Strategies. National Institute on
Drug Abuse Research Monograph 47. DHHS
Pub. No. (ADM)83-1280. Washington, DC:
Supt. of Docs., U.S. Govt. Print. Off., 1985.
Perry, C.L., and Kelder, S.H. Models for effec-
tive prevention. JAdolesc Health 13:355-363,
1992.
Perry, C.L.; Killen, J.; Stinkard, L.A.; and
McAlister, A.L. Peer teaching and smoking
prevention among junior high students. Ado-
lescence 9:277 '-281, 1983.
Resnicow, K., and Botvin, G.J. School-based
substance use prevention programs: Why do
effects decay? Prev Med 22(4):484-490, 1993.
Richards, L.G. "Government Programs and Psy-
chological Principles in Drug Abuse Preven-
tion." Paper presented at the annual
convention of the American Psychological
Association, Washington, DC, 1969.
Schaps, E.; DiBartolo, R.; Moskowitz, J.; Palley,
C; and Churgin, S. A review of 127 drug
abuse prevention program evaluations. J Drug
Issues ll(l):17-43, 1981.
Schinke, S.P. Preventing teenage pregnancy. In:
Hersen, M.; Eisler, R.M.; and Miller, P.M.,
eds. Progress in Behavior Modification. 16th
ed. New York: Academic Press, 1984.
Schinke, S.P, and Gilchrist, L.D. Primary pre-
vention of tobacco smoking. J Sch Health
53:416-419, 1983.
Schinke, S.P, and Gilchrist, L.D. Preventing
cigarette smoking with youth. J Prim Prev
5:48-56, 1984.
Shope, J.T.; Dielman, T.E.; Butchart, A.T.; and
Campanelli, PC. An elementary school-based
alcohol misuse prevention program: A
followup evaluation. J Stud Alcohol 53:106-
121, 1992.
Snow, D.L.; Tebes, J.K.; Arthur, M.W.; and
Tapasak, R.C. Two-year followup of a social-
cognitive intervention to prevent substance
use. J Drug Educ 22:101-114, 1992.
Sussman, S.; Dent, C.W.; Stacy, A.W.; and Sun,
P. Project Towards No Tobacco Use: One-year
behavior outcomes. Am J Public Health
83:1245-1250, 1993.
Swisher, J.D. Prevention issues. In: Dupont, R.I.;
Goldstein, A.; and O'Donnell, J., eds. Hand-
book on Drug Abuse. Washington, DC: Na-
tional Institute on Drug Abuse, 1979.
Swisher, J.D., and Hoffman, A. Information: The
irrelevant variable in drug education. In:
Corder, B.W; Smith, R.A.; and Swisher, J.D.,
eds. Drug Abuse Prevention: Perspectives and
Approaches for Educators. Dubuque, IA:
William C. Brown, 1975.
Telch, M.J.; Killen, J.D.; McAlister, A.L.; Perry,
C.L.; and Maccoby, N. Long-term followup
of a pilot project on smoking prevention with
adolescents. J Behav Med 5:1-8, 1982.
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
2STEPS: 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.
References
Botvin, G.J.; Baker, E; Dusenbury, L.; Tortu, S.;
and Botvin, E.M. Preventing adolescent drug
abuse through a multimodal cognitive-behav-
ioral approach: Results of a 3-year study.
J Consult Clin Psychol 58(4):437-446, 1990.
Eggert, L.L. Social support in families: Stress,
coping, and adaptation. In: Albrecht, T.L.;
Adelman, M.B.; and Associates. Communi-
cating Social Support: Process in Context.
Beverly Hills, CA: Sage, 1987.
Eggert, L.L. Reconnecting At-Risk Youth: Drug
Users and Dropouts. National Institute on
Drug Abuse Grant No. R01-DA04530 (with
J.R. Herting and L.J. Nicholas), 1989.
Eggert, L.L. Preventing Suicide Lethality Among
Vulnerable Youth. National Institute of Men-
tal Health Grant No. R18-MH48139 (with
E.A. Thompson, J.R. Herting, and L.J. Nicho-
las), 1991.
Eggert, L.L. A Measure of Adolescent Potential
for Suicide. National Institute of Nursing Re-
search Grant No. R01-NR03550 (with E.A.
Thompson), 1994a.
Eggert, L.L. Anger Management for Youth: Stem-
ming Aggression and Violence. Bloomington,
IN: National Educational Service, 1994b.
Eggert, L.L. Promoting Competence and Sup-
port To Prevent Suicide Risk. National Insti-
tute of Nursing Research Grant No.
R01-NR-MH03548 (with E.A. Thompson),
1995.
Eggert, L.L. Preventing Drug Abuse: Parents and
Youth With Schools. National Institute on
Drug Abuse Grant No. R01-DA10317 (with
J.R. Herting, B.P Randell, and E. McCauley),
1996a.
Eggert, L.L. Psychosocial approaches in preven-
tion science: Facing the challenge with high-
risk youth. Commun Nurs Res 29:20-30,
1996b.
Eggert, L.L,. and Herting, J.R. Drug involvement
among potential dropouts and "typical" youth.
J Drug Educ 23:31-55, 1993.
Eggert, L.L., and Herting, J.R. Preventing teen-
age drug abuse: Exploratory effects of net-
work social support. Youth and Society
22:482-534, 1991.
Eggert, L.L.; Herting, J.R.; and Thompson, E.A.
The Drug Involvement Scale for Adolescents
(DISA). J Drug Educ 26(2): 101-130, 1996.
Eggert, L.L., and Nicholas, L.J. Speaking like a
skipper: "Skippin' an' gettin' high." J Lang
Soc Psychol 11:75-100, 1992.
Eggert, L.L.; Nicholas, L.J.; and Owen, L.M.
Reconnecting Youth: A Peer-Group Approach
to Building Life Skills. Bloomington, IN: Na-
tional Educational Service, 1995.
Eggert, L.L., and Parks, M.R. Communication
network involvement in adolescents' friend-
ships and romantic relationships. Commun
Yearbook 10:283-322, 1987.
Eggert, L.L.; Seyl, CD.; and Nicholas, L.J. Ef-
fects of a school-based prevention program
for potential high school dropouts and drug
abusers. Int J Addict 25(7):773-801, 1990.
70 National Conference on Drug Abuse Prevention Research
Eggert, L.L.; Thompson, E.A.; and Herting, J.R.
A Measure of Adolescent Potential for Sui-
cide (MAPS): Development and preliminary
findings. Suicide Life Threat Behav 24:359-
381, 1994.
Eggert, L.L.; Thompson, E.A.; Herting, J.R.; and
Nicholas, L.J. A prevention research program:
Reconnecting at-risk youth. Issues Merit
Health Nurs 15:107-135, 1994.
Eggert, L.L.; Thompson, E.A.; Herting, J.R.; and
Nicholas, L.J. Reducing suicide potential
among high-risk youth: Tests of a school-
based prevention program. Suicide Life Threat
Behav 25(2):276-296, 1995.
Eggert, L.L.; Thompson, E.A.; Herting, J.R.;
Nicholas, L.J.; and Dicker, B.G. Preventing
adolescent drug abuse and high school drop-
out through an intensive school-based social
network development program. Am J Health
Promot 8:202-215, 1994.
Gordon, R. An operational classification of dis-
ease prevention. In: Steinberg, J. A., and
Silverman, M.M., eds. Preventing Mental
Disorders. Rockville, MD: U.S. Department
of Health and Human Services, 1987.
Hansen, W.B. School-based substance abuse pre-
vention: A review of the state of the art in
curriculum, 1980-1990. Health Educ Res
7(3):403-430, 1992.
Hawkins, J.D.; Catalano, R.F.; and Miller, J.Y.
Risk and protective factors for alcohol and
other drug problems in adolescence and early
adulthood: Implications for substance abuse
prevention. Psychol Bull 112(1):64-105,
1992.
Herting, J.R. Predicting at-risk youth: Evalua-
tion of a sample selection model. (Abstract)
Commun Nurs Res 23:178, 1990.
Herting, J.R.; Eggert, L.L.; and Thompson, E.A.
A multidimensional model of adolescent drug
involvement. J Res Adolesc 6:325-361, 1996.
Institute of Medicine. Reducing Risks for Men-
tal Disorders: Frontiers for Preventive Inter-
vention Research. Washington, DC: National
Academy Press, 1994.
Kumpfer, K.L., and Alvarado, R. Strengthening
families to prevent drug use in multi-ethnic
youth. In: Botvin, G.; Schinke, S.; and
Orlandi, M., eds. Drug Abuse Prevention With
Multi-Ethnic Youth. Newbury Park, CA: Sage,
1995.
Montoya, C. Personal quote. In: What's Work-
ing in Education, Youth Care, and the Com-
munity? Bloomington, IN: National Ed-
ucational Service, 1997.
National Institute on Drug Abuse. Drug Abuse
Prevention: What Works. In: Drug Abuse Pre-
vention Package. NCADI #PREVPK.
Rockville, MD: U.S. Department of Health
and Human Services, National Institutes of
Health, National Institute on Drug Abuse,
1997.
National Institute on Drug Abuse. Coming To-
gether on Prevention. 27 min. U.S. Depart-
ment of Health and Human Services, National
Institutes of Health, National Institute on Drug
Abuse, 1994. Videotape.
Pentz, M.A.; Trebow, E.A.; Hansen, W.B.;
MacKinnon, D.P.; Dwyer, J.H.; Johnson,
C.A.; Flay, B.R.; Daniels, S.; and Cormack,
C. Effects of program implementation on ado-
lescent drug use behavior: The Midwestern
Prevention Project (MPP). Eval Rev 14:264-
289, 1990.
Powell-Cope, G.M., and Eggert, L.L. Psychoso-
cial risk and protective factors: Potential high
school dropouts vs. typical youth. In: National
Dropout Center Yearbook I. Using What We
Know About At-Risk Youth: Lessons From the
Field. Lancaster, PA: Technomic, 1994.
Randell, B.P.; Herting, J.R.; Eggert, L.L.; and
Thompson, E.A. Family influences, deviant
peer bonding, self-esteem, and adolescent
drug involvement, in press.
Schinke, S.P., and Gilchrist, L.D. Life Skills
Counseling With Adolescents. Baltimore, MD:
University Park, 1984.
Reconnecting Youth 71
Thompson, E.A.; Eggert, L.L.; Herting, J.R.; and
Nicholas, L.J. Mediating effects of preven-
tion program elements on suicide risk behav-
iors. Suicide Life Threat Behav, n.d.
Thompson, E.A.; Horn, M.; Herting, J.H.; and
Eggert, L.L. Enhancing outcomes in an indi-
cated drug prevention program for high-risk
youth. J Drug Educ 27:19-41, 1997.
Thompson, E.A.; Moody, K.A.; and Eggert, L.L.
Discriminating suicide ideation among high-
risk youth. J Sch Health 64(9):361-367, 1994.
Tobler, N.S. Meta-analysis of 143 adolescent
drug prevention programs: Quantitative out-
come results of program participants com-
pared to a control or comparison group.
J Drug Issues 16:537-567, 1986.
Tobler, N.S. Drug prevention programs can work:
Research findings. J Addict Dis 11(3): 1-28,
1992.
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
co
E
?
Q.
C
.o
c
s
I
■Q
Q)
CO
CtS
■Q
E
£
o
o
O
■£2
o
"O
c
cc
.8
o
CO
s
UJ
E
o O)
"6
w
2
CD
to
« 8
C 3
UJ
CO
CD
0>
CJ
CD c
cd <S
co 2
2 —
cd co
t: o
o
Q.
CD
O
.5 CD
EiS
Q E
z
CO .9
g
o
OJ
c
c
J*
>
o
E
aj
co
c
■D
_—
CD
s
CO
c
CO
CD
0>
o
CD
CO
Q.
■a
+
c
O
CD
o
n
5
cj
a.
to
CD <0
co o
co
C CD
o £
o
■o a>
JJJ
CD =
>< co
CD
co ^
o
s >
z
Q 5
CO CO -9
>- o .5
0) 3 O
■d -a ^
co cd jr
03 - (0
>.? =
:£ ~ CD
£ 1 E co
3 CO ^ CD
| it|
O CD O O
O Q. CJ CO
D) °
CO
T3
C CD
CO CD
CD
E
CO
D)
C
T 2
CO
-O
CO
JD
O _
E
O
CO o
co"
a"
O 3
<fl
C3>
CO
E 5
CO J=
O CO
O =5
0)
as
E
CD
>
o
o
c
o
«
o
■D
LU
CD
cn
CO
I
M
|S
O -a
X CD
col
^- >l
II
CD CO
I s
o -a
X CD
^•1
CD o
|r
■s 8.
CD '
O ^
CD CO
CD C3>
1°
o? E
CO CO
O CO
CL cfl
co
£
CD
co
1 =
= E
CO
€ E
CD
« °
c
CO o
CO
"6 co-
**
CD" CO c:
co
CO
CD
sk fore
materi
ucatioi
O
CD
CJ
I
O
P o"S
c
C
- CO
CD C
o
O")
D) O)
o
3
'cO
a.
E
2 'co
CD Q-
O o
73
CO
LU
O
o
CD
E
o
I
■c
LU
o
o
o
o
o
CO
CO
co
* cn
CO
o
c
o
o J*
o
3
3
3
3 ^
3
-o
-o
■D
■o <
■o
UJ
UJ
UJ
UJ CO
UJ
>
CO
g>
T3
S » »
O) C CD
2 £ 0.
■O O
cm £.55
o
CO
ro
c
CD
>
CD
g
o
Q.
CJ
05 O
CD
C
in
^3
o
:;
.2
E
CO
CD
>
CD
o
CD
C c
<!> co -^
> c «
0) t «
C5.3 •
£ ^ -^ CM
" = S S
_, *- O) C35
CM CO t- l—
O CO
C CD
IMS
If «s
C CO
CO .
H- O
cd a>
>_ CJ)
2 >.
Q. 2
° i.—
CO 3 S
O J3
S C Or
C CD C c
CD CO CD O
> O ~> CO
SCSz
CO D)
CD C
£ O) _: S
55 £ u -= -
Sl2
O
CO '*
CD O)
-; cn o)
CO I- T—
5 CO
X3 CD
CO T3
O 3
CO 1o
cu cTg co
CJ CO
9 »
5 >-?
2 I -a
_g
ffi
U to
76 National Conference on Drug Abuse Prevention Research
O D)
"6
CD
•A
c
o
I-
CL CD
$ 8
o co
£ S.
.£ co
£1
o o
o =
3 73
o>2
"D C
<" ^
CO T3
(0 CD
a) t:
CD C1-
Q 2
c
— 0)
■8 £
cd
O)
c
CD
Q- Q)
>
^
CO
CD
C CO
■p
o *-
c co
TJ
■J= CD
CD *-
3
C >_
> CD
T—
HI
co
CD O
II
>- CO
2 >,
■^ CD
_l
cu
^^
E9^
ffl
<
Q.
° >.— ■
^ -o 56
CO 3 S
1-
z
t- CD
f Mi-
•= CD
o ~
co en
"O o
LU o
:= 3
Q. CD
— CD
0)
CD
CD
D)
O)
Q. LU
r- CO i-
5 «
CD ®
£§
Dl CO
C CO
2 3
8 £
E -d jr
1- CO 1—
§2*
Si,
03 o ~
c « =
§ 9> g
CD
CD Q-
>. Q.
=>, f ■ — O
— cn c =
£ - . o P
c
o
- 3 n ffl
E o 8 9>
£ ■£ "53 co
o
E en
>s
03
CO CO
CJ
o
O) CD
3
o >
O
•D
f- o
Q-
CD
0- o
■
c
CD
>=; C
E
c
c
§ O
CD
g
o
5 «s
«- CJ
CD CO
<= O
CD 4+=-
to
ro
§ s
o
o
c c
3
3
£3
Q_ 9?
CD
LU
c
.9 en
= -s
■° -9
LU 2
CD
52 <"
8-f
si
"D _C0
^S —
co Q
c
o
cd"
■d
55
o
S
en
o 9>
O CO
CD
■a c
'C CO
co
-* E
<D o
P
05 s
i2 2
D.
DC ro
CO
O
(1)
■^
m
i )
CD
-i
CD
n
LL
Hi
.9 c (0 CD
c o « 5
CD CO v ^
> C N N
£ £ C C
Q--8 ^ ^
•D d Ol CO
■r- -s °2 °2
c <u
CD c
Ol
8£
° >,~
^ -a 56
i- CO ■>—
8 5i « _
c co .9 £
3 CD "^ a>
E o o "
E > 3 o
,9 <t> a) c
(J co c cd
.9 c
CD
a>
c
co
£
CO
$•1 8
'= - E
o g
3
E e
° o c
O o hi
9 c
ECO
. Q.
o E
o
co
■£ co
2 cd
"§ E To
CO "D CD
CO J2
9 3
.9 co
a. cnj to T 0-
0>X£S 0)
c i2
' 2 5 <3 5 S
7- CO T) -i< T-
■o
CD
C
CO ^
CO
LL
o
III
co
O
CD
11
CD
3
cr
n
«
CO
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
—
^^^~~
__ ■
" +'
-
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.
References
Ajzen, I., and Fishbein, M. Understanding Atti-
tudes and Predicting Social Behavior.
Englewood Cliffs, NJ: Prentice-Hall, 1980.
Bachman, J.G.; Johnston, L.D.; and O'Malley,
P.M. Explaining the recent decline in cocaine
use among young adults: Further evidence
that perceived risk and disapproval lead to
reduced drug use. J Health Soc Behav
31(2):173-184, 1990.
Bandura, A. Social Learning Theory. Englewood
Cliffs, NJ: Prentice-Hall, 1977.
Barthold, J.; Pearson, J.; Ellsworth, A.; Mason,
C; Hohensee, T.; McLaud, B.; and Lewis, C.
A cardiovascular health education program for
rural schools. J Sch Health 63(7):298- 301,
1993.
Boruch, R.F., and Shadish, W.R. Design issues
in community intervention research. In:
Seidman, E., ed. Handbook of Social Inter-
vention. Beverly Hills, CA: Sage, 1983.
Botvin, G.J.; Baker, E.; Dusenbury, L.; Botvin,
E.M.; and Diaz, T. Long-term followup re-
sults of a randomized drug abuse prevention
trial in a white middle-class population. JAMA
273(14): 1106-1112, 1995.
Botvin, G.J.; Baker, E.; Dusenbury, L.; Tortu, S.;
and Botvin, E.M. Preventing adolescent drug
abuse through a multimodal cognitive-behav-
ioral approach: Results of a 3 -year study. J
Consult Clin Psychol 58(4):437-446, 1990.
Carlson, K.A. Identifying the outcomes of pre-
vention: Results of a longitudinal study in a
small city school district. J Drug Educ
24(3): 193-206, 1994.
Center for Substance Abuse Prevention. Phase
II, National Evaluation of the Community
Partnership Demonstration Program Techni-
cal Assistance Meeting. Washington, DC,
August 1-2, 1996.
Eggert, L.L.; Seyl, CD.; and Nicholas, L.J. Ef-
fects of a school-based prevention program
for potential high school dropouts and drug
abusers. Int J Addict 25(l):ll?>-m\, 1990.
Ray, B.R.; Miller, T.Q.; Hedeker, D.; Siddequi,
O.; Britton, C.F.; Brannon, B.R.; Johnson,
C.A.; Hansen, W.B.; Sussman, S.; and Dent,
C. The television, school, and family smok-
ing prevention and cessation project. Prev
Med 24:29-40, 1995.
Flay, B.R.; Pentz, M.A.; Johnson, C.A.; Sussman,
S.; Mestell, J.; Scheier, L.; Collins, L.M.; and
Hansen, W.B. Reaching children with mass
media health promotion programs: The rela-
tive effectiveness of an advertising campaign,
a community-based program, and a school-
based program. In: Leathar, D.S., ed. Health
Education and the Media. 2d ed. Oxford,
England: Pergamon Press, 1985.
Flynn, B.S.; Worden, J.K.; Seeker-Walker, R.H.;
Badger, G.J.; Geller, B.M.; and Costanza,
M.C. Prevention of cigarette smoking through
mass media intervention and school programs.
Am J Public Health 82(6):827-834, 1992.
Goodman, R.M.; Wandersman, A.; Chinman, M.;
Imm, P.; and Morrisey, E. An ecological as-
sessment of community-based interventions
for prevention and health promotion: Ap-
proaches to measuring community coalitions.
Am J Community Psychol 24:33-61, 1996.
Gottlieb, N.H.; Brink, S.G.; and Gingiss, PH.
Correlates of coalition effectiveness: The
Smoke-Free Class of 2000 program. Special
Issue: Community coalitions for health pro-
motion. Health Educ Res 8(3):375-384, 1993.
Hingson, R.; McGovern, T; Howland, J.; Heeren,
T; Winter, M.; and Zakocs, R. Reducing
alcohol-impaired driving in Massachusetts:
The saving lives program. Am J Public Health
86(6): 792-797, 1996.
84 National Conference on Drug Abuse Prevention Research
Jason, L.A.; Ji, P.Y.; Anes, M.D.; and Birkhead,
S.H. Active enforcement of cigarette control
laws in the prevention of cigarette sales to
minors. JAMA 266(22):3159-3161, 1991.
Johnson, C.A.; Pentz, M.A.; Weber, M.D.;
Dwyer, J.H.; MacKinnon, D.P.; Flay, B.R.;
Baer, N.A., and Hansen, W.B. Relative effec-
tiveness of comprehensive community pro-
gramming for drug abuse prevention with
high-risk and low-risk adolescents. J Consult
Clin Psychol 58(4): 447-456, 1990.
Johnston, L.D. Changing trends, patterns, and
nature of marijuana use. In: National Confer-
ence on Marijuana Use: Prevention, Treat-
ment, and Research: Conference Highlights.
NIH Pub. No. 96-4106. Washington, DC:
Supt. of Docs., U.S. Govt. Print Off., 1996.
Johnston, L.D.; O'Malley, P.M.; and Bachman,
J.G. National Survey Results on Drug Use
From the Monitoring the Future Study, 1975-
1993: Volume 1. Secondary School Students.
NIH Pub. No. 94-3809. Rockville, MD: U.S.
Department of Health and Human Services,
National Institutes of Health, National Insti-
tute on Drug Abuse, 1994.
Kantor, G.K.; Caudill, B.D.; and Ungerleider S.
Project Impact: Teaching the teachers to in-
tervene in student substance abuse problems.
J Alcohol Drug Educ 31(1): 11-27 ', 1992.
Kaufman, J.S.; Jason, L.A.; Sawlski, L.M.; and
Halpert, J. A. A comprehensive multimedia
program to prevent smoking among black stu-
dents. J Drug Educ 24(2):95-108, 1994.
Koepsell, T.D.; Wagner, E.H.; Cheadle, A.C.;
Patrick, D.L.; Martin, D.C.; Diehr, PH.;
Perrin, E.B.; Kristal, A.R.; Allan- Andrilla,
C.H.; and Dey, L.J. Selected methodological
issues in evaluating community-based health
promotion and disease prevention programs.
Ann Rev Public Health 13:31-57, 1992.
Manger, T.H.; Hawkins, J.D.; Haggerty, K.P.; and
Catalano, R.F. Mobilizing communities to re-
duce risks for drug abuse: Lessons on using
research to guide prevention practice. J Prim
Prev 13(l):3-22, 1992.
Mansergh, G.; Rohrbach, L.; Montgomery, S.B.;
Pentz, M.A.; Johnson, C.A. Process evalua-
tion of community coalitions for alcohol and
other drug prevention: Comparison of two
models. J Community Psychol 24:118-135,
1996.
Mittelmark, M.B.; Hunt, M.K.; Heath, G.W.; and
Schmid, T.L. Realistic outcomes: Lessons
from community-based research and demon-
stration programs for the prevention of car-
diovascular diseases. J Public Health Policy
14(4):437-462, 1993.
Murray, D.M.; Prokhorov, A.V.; and Harty, K.C.
Effects of a statewide antismoking campaign
on mass media messages and smoking beliefs.
Prev Med 23(1 ):54-60, 1994.
Pentz, M.A. Community organization and school
liaisons: How to get programs started. J Sch
Health 56:382-388, 1986.
Pentz, M.A. Benefits of integrating strategies
in different settings. In: Elster, A.; Panzarine,
S.; and Holt, K. eds. American Medical As-
sociation State-of-the-Art Conference on Ado-
lescent Health Promotion: Proceedings.
NCEMCH Research Monograph, 15-34,
1993.
Pentz, M.A. Adaptive evaluation strategies for
estimating effects of community-based drug
abuse prevention programs. J Community
Psychol Special Issue:26-51, 1994a.
Pentz, M.A. Primary prevention of adolescent
drug abuse. In: Fisher, C.B., and Lerner, R.M.,
eds. Applied Developmental Psychology. New
York: McGraw-Hill, 19946.
Pentz, MA. The school-community interface in
comprehensive school health education. In:
Stansfield, S., ed. Institute of Medicine An-
nual Report. Committee on Comprehensive
School Health Programs, Institute of Medi-
cine, Bethesda, MD. Washington, DC: Na-
tional Academy Press, 1995.
Pentz, M.A. Cost benefits and cost-effectiveness
research in drug abuse prevention: Implica-
tions for programming and policy. In:
Multicomponent Programs Make the Difference 85
Bukoski, W., and Evans, R.I., eds. National
Institute on Drug Abuse Research Monograph
177, U.S. Department of Health and Human
Services, National Institutes of Health, Na-
tional Institute on Drug Abuse, in press.
Pentz, M.A. Lessons learned from community-
based prevention: The Midwestern Preven-
tion Project. CSAP NPERC Prevention
Evaluation Report, in press.
Pentz, M.A.; Dwyer, J.H.; MacKinnon, D.P;
Flay, B.R.; Hansen, W.B.; Wang, E.Y.; and
Johnson, C. A. A multicommunity trial for pri-
mary prevention of adolescent drug abuse: Ef-
fects on drug use prevalence. JAMA
261(22):3259-3266, 1989.
Perry, C.L.; Kelder, S.H.; Murray, D.M.; and
Klepp, K.I. Community wide smoking preven-
tion: Long-term outcomes of the Minnesota
Health Heart Program and the Class of 1989
Study. Am J Public Health 82(9): 1210-1216,
1992.
Perry, C.L.; Williams, C.L.; Forster, J.L.;
Wolfson, M.; Wagenaar, A.C.; Finnegan, J.R.;
Mcgovern, PC; Veblenmortenson, S.; and
Komro, K.A., et al. Background, con-
ceptualization and design of a community-
wide research program on adolescent alcohol
use — Project Northland. Health Educ Res
8(1):125-136, 1993.
Petraitis, J., and Flay, B.R. The theory of triadic
influence: A new theory of health behavior
with implications for preventive interventions.
A dv Med Sociol 4: 19-44, 1994.
Petraitis, J.; Flay, B.R.; and Miller, T.Q. Review-
ing theories of adolescent substance use: Or-
ganizing pieces in the puzzle. Psychol Bull
117(l):67-86, 1995.
Rogers, E.M., and Storey, J.D. Communication
campaigns. In: Berger, C.R., and Caffee, S.H.,
eds. Handbook of Communication Science.
Newbury Park, CA: Sage Publications, 1987.
Rosenbaum, D.P; Flewelling, R.L.; Bailey, S.L.;
Ringwalt, C.L.; et al. Cops in the classroom:
A longitudinal evaluation of Drug Abuse Re-
sistance Education (DARE). J Res Crime De-
linquency 31(1):3-31, 1994.
Rothman, M.L. "The Potential Benefits and
Costs of a Comprehensive School Health Edu-
cation Program." Unpublished manuscript,
1995.
Rotter, J.B. Social Learning and Clinical Psy-
chology. New York: Prentice-Hall, 1954.
St. Pierre, T.L.; Kaltreider, D.L.; Mark, N.N.; and
Aikin, K.J. Drug prevention in a community
setting: A longitudinal study of the relative
effectiveness of a 3-year primary prevention
program in Boys and Girls Clubs across the
Nation. Am J Community Psychol 20(6):673-
706, 1992.
Saxe, L.; Reber, E.; Hallyfors, D.; and Stirratt,
M.J. "Taking the Long View. Evaluating
Community-Based Efforts To Reduce Sub-
stance Abuse." Unpublished manuscript.
Schinke, S.P; Orlandi, M.A.; and Cole, K.C.
Boys and Girls Clubs in public housing de-
velopment: Prevention services for youth at
risk. J Community Psychol Special Issue: Pro-
grams for change: Office for Substance Abuse
Prevention demonstration models. 118-128,
1992.
Shea, S.; Basch, C.E.; Lantigua, R.; and
Wechsler, H. The Washington Heights-
Inwood Healthy Heart Program: A third-gen-
eration community-based cardiovascular
disease prevention program in a disadvan-
taged urban setting. Prev Med 21(2):203-217,
1992.
Sobol, D.F.; Rohrbach, L.A.; Dent, C.W.;
Gleason, L.; Brannon, B.R.; Johnson, C.A.;
and Flay, B.R. The integrity of smoking pre-
vention curriculum delivery. Health Educ Res
4:59-67, 1989.
Stevens, M.M.; Freeman, D.H.; Mott, L.A.;
Youells, F.E.; andLinsey, S.C. Smokeless to-
bacco use among children: The New Hamp-
shire Study. Am J Prev Med 9(3): 160-167,
1993.
Wiener, R.L.; Pritchard, C; Frauenhoffer, S.M.;
and Edmonds, M. Evaluation of a drug-free
schools and community program: Integration
of qualitative and quasi-experimental meth-
ods. EvalRev 17(5):488-503, 1993.
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
^ApPrai, ■ ':-.;: _*,***
urce Room
ettjng 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.
References
Achenbach, T.M., and Howell, C.T. Are Ameri-
can children's problems getting worse? A 13-
year comparison. J Am Acad Child Adolesc
Psychiatry 32:1145-1154, 1993.
Alexander, J.F., and Parsons, B.V. Short-term
behavioral intervention with delinquent fami-
lies: Impact on family process and recidivism.
J Abnorm Psychol 81:219-225, 1973.
Arnold, J.; Levine, A.; and Patterson, G.R.
Changes in sibling behavior following fam-
ily intervention. J Consult Clin Psychol
43:683-688, 1975.
Bank, L.; Marlowe, J.H.; Reid, J.B.; Patterson,
G.R.; and Weinrott, M.A. Comparative evalu-
ation of parent training for families of chronic
delinquents. J Abnorm Child Psychol 19:15-
33, 1991.
Baumrind, D. Familial antecedents of adolescent
drug use: A developmental perspective. In:
Jones, C.L., and Battjes, R.J., eds. Etiology
of Drug Abuse: Implications for Prevention.
National Institute on Drug Abuse Research
Monograph 56. DHHS Pub. No. (ADM)87-
1335. Washington, DC: Supt. of Docs., U.S.
Govt. Print. Off., 1985.
Block, J.; Block, J.H.; and Keyes, S. Longitudi-
nally foretelling drug usage in adolescence:
Early childhood personality and environmen-
tal precursors. Child Dev 59:336-355, 1988.
Advances in Family-Based Interventions 95
Brown, J., and Miller, W. Impact of motivational
interviews on participation and outcome in
residential alcoholism treatment. Psychol of
Addict Behav 7:211-218, 1993.
Bry, B., and Canby, C. Decreasing adolescent
drug use and school failure: Long-term effects
of targeted family problemsolving training.
Child Fam Behav Ther 8:43-59, 1986.
Bry, B.H.; McKeon, P.; and Pandina, R.J. Extent
of drug use as a function of number of risk
factors. JAbnorm Psychol 91:273-279, 1982.
Buchanan, CM.; Maccoby, E.E.; and Dornbusch,
S.M. Caught between parents: Adolescents'
experience in divorced homes. Child Dev
62(5): 1008-1029, 1991.
Cairns, R.B.; Cairns, B.D.; Neckerman, H.J.;
Gest, S.D.; and Gariepy, J. Social networks
and aggressive behavior: Peer support or peer
rejection. Dev Psychol 24:815-823, 1988.
Campbell, S.B. Hard-to-manage preschool boys:
Externalizing behavior, social competence,
and family context at 2-year followup. J Ah
Child Psychol 22: 147 -166, 1994.
Capaldi, D., and Patterson, G.R. The relation of
parental transitions to boys' adjustment prob-
lems: I. A test of linear hypothesis. II. Moth-
ers at risk for transitions and unskilled
parenting. Dev Psychopathol 3:277-300,
1991.
Chassin, L.; Presson, C.C.; Sherman, S.J.;
Montello, D.; and McGrew, J. Changes in peer
and parent influence during adolescence: Lon-
gitudinal versus cross- sectional perspectives
on smoking initiation. Dev Psychol 22:327-
334, 1986.
Christensen, A., and Jacobson, N.S. Who (or
what) can do psychotherapy? The status and
challenge of nonprofessional therapies.
Psychol Sci 5:8-14, 1994.
Coatsworth, J.D.; Szapocznik, J.; Kurtines, W.;
and Santisteban, D.A. Culturally competent
psychosocial interventions with antisocial
problem behavior in Hispanic youths. In:
Stoff, D.M.; Breiling, J.; and Maser, J.D., eds.
Handbook of Antisocial Behavior. New York:
John Wiley and Sons, 1996.
Coie, J.D., and Kupersmidt, J.B. A behavioral
analysis of emerging social status in boys
groups. Child Dev 54:1400-1416, 1983.
Conger, R.D.; Conger, K.J.; Elder, G.H., Jr.;
Lorenz, F.O.; Simons, R.L.; and Whitbeck,
L.B. A family process model of economic
hardship and adjustment of early adolescent
boys. Child Dev 63:526-541, 1992.
Cronbach, L.J., and Glesar, G.C. Psychological
Tests and Personnel Decisions. Urbana, IL:
University of Illinois Press, 1965.
Dadds, M.R.; Sanders, M.R.; Morrison, M.; and
Rebgetz, M. Childhood depression and con-
duct disorder: II. An analysis of family inter-
action patterns in the home. JAbnorm Psychol
101:505-513, 1992.
Dishion, T.J. Peer context of troublesome behav-
ior in children and adolescents. In: Leone, P.,
ed. Understanding Troubled and Troublesome
Youth. Beverly Hills, CA: Sage, 1990.
Dishion, T.J.; Eddy, J.M.; Haas, E.; Li, E; and
Spracklen, K. Friendships and violent behav-
ior during adolescence. Soc Dev 6(2):207-223,
1997.
Dishion, T.J.; French, D.; and Patterson, G.R. The
development and ecology of antisocial behav-
ior. In: Cicchetti, D., and Cohen, D., eds.
Manual of Developmental Psychopathology:
Vol. 2. Risk, Disorder, and Adaptation. New
York: John Wiley and Sons, 1995.
Dishion, T J., and Kavanagh, K. Adolescent Prob-
lem Behavior: An Intervention and Assess-
ment Sourcebook for Working With Families
in Schools. New York: Guilford Press, in
press.
Dishion, T.J.; Li, F; Spracklen, K.M.; Brown,
G.; and Haas, E. The measurement of
parenting practices in research on adolescent
problem behavior: A multimethod and
multitrait analysis. In: Ashery, R.S.; Kumpfer,
K.L.; and Robertson, E., eds. Drug Abuse Pre-
vention Through Family Interventions. Na-
tional Institute on Drug Abuse Research
Monograph 177. U.S. Department of Health
96 National Conference on Drug Abuse Prevention Research
and Human Services, National Institutes of
Health, National Institute on Drug Abuse, in
press.
Dishion, T.J., and Loeber, R. Male adolescent
marijuana and alcohol use: The role of par-
ents and peers revisited. Am J Drug Alcohol
Abuse 11:11-25, 1985.
Dishion, T.J., and McMahon, R.J. Parental moni-
toring and the prevention of child and ado-
lescent problem behavior: A conceptual and
empirical reformulation. Clin Child Family
Psychol Rev 1:61-75, 1998.
Dishion, T.J., and Patterson, G.R. Age effects in
parent training outcome. Behav Ther 23:719-
729, 1992.
Dishion, T.J.; Patterson, G.R.; Stoolmiller, M.;
and Skinner, M.L. Family, school, and behav-
ioral antecedents to early adolescent involve-
ment with antisocial peers. Dev Psychol
27:172-180, 1991.
Dodge, K.A. Behavioral antecedents: A peer so-
cial status. Child Dev 54:1386-1399, 1983.
Dumas, J.E. Treating antisocial behavior in chil-
dren: Child and family approaches. Clin
Psychol Rev 9:197 '-222, 1989.
Elder, G.H.; Nguyen, TV.; and Caspi, A. Link-
ing family hardship to children's lives. Spe-
cial Issue: Family development. Child Dev
56:361-375, 1985.
Elliott, D.; Huizinga, D.; and Ageton, S. Explain-
ing Delinquency and Drug Use. Beverly Hills,
CA: Sage, 1985.
Forgatch, M.S.; Patterson, G.R.; and Skinner,
M.L. A mediational model for the effect of
divorce on antisocial behavior in boys. In:
Hetherington, E.M., and Arasteh, J.D., eds.
Impact of Divorce, Single Parenting, and
Step-Parenting on Children. Hillsdale, NJ:
Erlbaum, 1988.
Friedman, A.S. Family therapy versus parent
groups: Effects on adolescent drug abusers.
AmJFam Ther 17:335-347, 1989.
Greenwood, P.; Rydell, C.; Abrahams, A.;
Caulkins, J.; Chiesa, J.; Model, K; and Klein,
S. Diverting Children From a Life of Crime:
Measuring Costs and Benefits. Santa Monica,
CA: Rand, 1994.
Hawkins, J.D.; Catalano, R.F.; and Miller, J.Y.
Risk and protective factors for alcohol and
other drug problems in adolescence and early
adulthood: Implications for substance abuse
prevention. Psychol Bulletin 112(1):64-105,
1992.
Henggeler, S. W. An ecological approach to treat-
ment: An interview with Scott Henggeler. The
Scientist Practitioner 3:10-17, 1993.
Henggeler, S.W.; Melton, G.B.; and Smith, L.A.
Family preservation using multisystemic
treatment: An effective alternative to incar-
cerating serious juvenile offenders. J Consult
Clin Psychol 60:953-961, 1992.
Henggeler, S. W.; Melton, G.B.; Brondino, M.J.;
Scherer, D.G.; et al. Multisystemic therapy
with violent and chronic juvenile offenders
and their families: The role of treatment fi-
delity in successful dissemination. / Consult
Clin Psychol 65(5):821-833, 1997.
Henggeler, S.W.; Rodnick, J.D.; Borduin, CM.;
Hanson, C.L.; Watson, S.M.; and Urey, J.R.
Multisystemic treatment of juvenile offend-
ers: Effects on adolescent behavior and fam-
ily interaction. Dev Psychol 22:132-141,
1986.
Johnson, S.M., and Christensen, A. Multiple cri-
teria followup of behavior modifications with
families. JAbnorm Child Psychol 3:135-154,
1975.
Kazdin, A.E. Treatment of conduct disorder:
Progress and directions in psychotherapy re-
search. Dev Psychopathol 5:277-310, 1993.
Kellam, S.G.; Brown, C.H.; Rubin, B.R.; and
Ensminger, M.E. Paths leading to teenage
psychiatric symptoms and substance use: De-
velopmental epidemiological studies in
Woodlawn. In: Guze, S.R.; Earns, F.J.; and
Barrett, J.E., eds. Childhood Psychopathol-
ogy and Development. New York: Raven
Press, 1983.
Kumpfer, K.L.; Molgaard, V.; and Spoth, R. The
"Strengthening Families Program" for the
prevention of delinquency and drug abuse. In:
Peters, R.D., and McMahon, R.J., eds. Pre-
venting Childhood Disorders, Substance
Abuse, and Delinquency. Newbury Park, CA:
Sage, 1996.
Advances in Family-Based Interventions 97
Lewis, R.A.; Piercy, F.P.; Sprendle, D.H.; and
Trepper, T.J. Family-based interventions for
helping drug-using adolescents. JAdolesc Res
5:82-95, 1990.
Loeber, R., and Dishion, T. Early predictors of
male delinquency: A review. Psychol Bull
94:68-99, 1983.
Loeber, R.; Dishion, T.J.; and Patterson, G.R.
Multiple gating: A multistage assessment pro-
cedure for identifying youths at risk for de-
linquency. J Res Crime Delinquency 21:7 '-32,
1984.
Maccoby, E.E.; Depner, C.E.; and Mnookin, R.H.
Coparenting in the second year after divorce.
J Marriage Fam 52:141-155, 1990.
Mathias, R. Students' use of marijuana, other il-
licit drugs, and cigarettes continued to rise in
1995. NIDA Notes. NIH Pub. No. 96-3478.
Washington, DC: Supt. of Docs., U.S. Govt.
Print. Off., 1996.
McLoyd, V.C. The impact of economic hardship
on black families and children: Psychologi-
cal distress, parenting, and socioemotional de-
velopment. Special Issue: Minority children.
Child Dev 61:311-346, 1990.
McMahon, R.J.; Tiedemann, G.L.; Forehand, R.;
and Griest, D.L. Parental satisfaction with par-
ent training to modify child noncompliance.
Behav Ther 15:295-303, 1993.
Miller, W.R., and Rollnick, S. Motivational In-
terviewing: Preparing People To Change Ad-
dictive Behavior. New York: Guilford Press,
1991.348 pp.
Oetting, E.R., and Beauvais, F. Peer cluster
theory, socialization characteristics, and ado-
lescent drug use: A path analysis. / Counsel
Psychol 34(2):205-213, 1987.
Patterson, G.R. Interventions for boys with con-
duct problems: Multiple settings, treatments,
and criteria. / Consult Clin Psychol 42:471-
481, 1974.
Patterson, G.R. Beyond technology: The next
stage in developing an empirical base for
training. In: L Abate, L., ed. Handbook of
Family Psychology and Therapy. Vol. 2.
Homewood, IL: Dorsey Press, 1985.
Patterson, G.R. Performance models for antiso-
cial boys. Am Psychol 41:432-444, 1986.
Patterson, G.R., and Chamberlain, P. Afunctional
analysis of resistance during parent training
therapy. Clin Psychol Sci Pract 1:53-70, 1994.
Patterson, G.R.; DeBaryshe, B.D.; and Ramsey,
E. A developmental perspective on antisocial
behavior. Am Psychol 44:329-335, 1989.
Patterson, G.R., and Dishion, T.J. Contributions
of families and peers to delinquency. Crimi-
nology 23:63-79, 1985.
Patterson, G.R.; Dishion, T.J.; and Chamberlain,
P. Outcomes and methodological issues re-
lating to treatment of antisocial children. In:
Giles, T.R., ed. Handbook of Effective Psy-
chotherapy. New York: Plenum, 1993.
Patterson, G.R., and Forgatch, M.S. Therapist
behavior as a determinant for client resistance:
A paradox for the behavior modifier. J Con-
sult Clin Psychol 53:846-851, 1985.
Patterson, G.R.; Reid, J.B.; and Dishion, T.J.
Antisocial Boys. Eugene, OR: Castalia, 1992.
Pentz, M.A.; MacKinnon, D.P.; Dwyer, J.H.;
Wang, E.Y.J. ; Hansen, W.B.; Flay, B.R.; and
Johnson, C.A. Longitudinal effects of the
Midwestern Prevention Project on regular and
experimental smoking in adolescents. Prev
Med 18:304-321, 1989.
Prinz, R.J., and Miller, G.E. Family-based treat-
ment for childhood antisocial behavior: Ex-
perimental influences on dropout and
engagement. J Consult Clin Psychol 62:645-
650, 1994.
Prochaska, J.O., and DiClemente, C.C. Trans-
theoretical therapy: Toward a more integrated
model of change. Psychother Theory Res
Pract 19:276-288, 1982.
Prochaska, J.O., and DiClemente, C.C. Toward
a comprehensive model of change. In: Miller,
W., and Heather, N., eds. Treating Addictive
Behaviors: Processes of Change. New York:
Plenum Press, 1986.
98 National Conference on Drug Abuse Prevention Research
Prochaska, J.O.; Velicer, W.F.; Guadagnoli, E.;
and Rossi, J.S. Patterns of change: Dynamic
typology applied to smoking cessation.
Multivar Behav Res 26:83-107, 1991.
Robins, L.N., and Przybeck, T.R. Age of onset
of drug use as a factor in drug and other dis-
orders. In: Jones, C.L., and Battjes, R.J., eds.
Etiology of Drug Abuse: Implications for Pre-
vention. National Institute on Drug Abuse
Research Monograph 56. DHHS Pub. No.
(ADM)87-1335. Washington, DC: Supt. of
Docs., U.S. Govt. Print. Off., 1985.
Robins, M.S.; Alexander, J.F.; Newell, R.N.; and
Turner, C.W. The immediate effect of
reframing on client attitude and family
therapy. J Fam Psychol 10:23-34, 1996.
Schmidt, S.E.; Liddle, H.A.; and Dakof, G.A.
Changes in parenting practices and adoles-
cent drug abuse during multidimensional fam-
ily therapy. J Fam Psychol 10:12-27, 1996.
Smith, G.M., and Fogg, C.P. Psychological an-
tecedents of teenage drug use. Res Commu-
nity Ment Health 1:87-102, 1979.
Spoth, R., and Redmond, C. Illustrating a frame-
work for rural family prevention research. In:
Peters, R.D., and McMahon, R.J., eds. Pre-
venting Childhood Disorders, Substance
Abuse, and Delinquency. Thousand Oaks, CA:
Sage, 1996.
St. Pierre, T.L.; Mark, M.M.; Kaltreider, D.L.;
and Aikin, K.J. Involving parents of high-risk
youth in drug prevention: A 3-year longitudi-
nal study in Boys and Girls Clubs. J Early
Adolesc 17:21-50, 1997.
Stoolmiller, M. Antisocial behavior, delinquent
peer association, and unsupervised wander-
ing for boys: Growth and change from child-
hood to early adolescence. Multivar Behav
Res 29:263-288, 1994.
Szapocznik, J., and Kurtines, W.M. Break-
throughs in Family Therapy With Drug-
Abusing and Problem Youth. New York:
Springer, 1989.
Szapocznik, J.; Kurtines, W.M.; and Fernandez,
T Bicultural involvement and adjustment in
Hispanic- American youths. Int J Intercult Rel
4:353-366, 1980.
Szapocznik, J.; Kurtines, W.; Santisteban, D.A.
Pantin, H.; Scopetta, M.; Mancilla, Y.
Aisenberg, S.; Macintosh, S.; Perez- Vidal, A.
and Coatsworth, J.D. The evolution of a struc-
tural ecosystems theory for working with His-
panic families in culturally pluralistic
contexts. In: Garcia, J.G., and Zea, M.C., eds.
Psychological Interventions and Research
With Latino Populations. Boston: Allyn and
Bacon, 1997.
Szapocznik, J.; Perez- Vidal, A.; Brickman, A.L.;
Foote, F.H.; Santisteban, D.; Hervis, O.; and
Kurtines, W.M. Engaging adolescent drug
abusers and their families in treatment: A stra-
tegic structural systems approach. J Consult
Clin Psychol 56(4):552-557, 1988.
Szapocznik, J.; Santisteban, D.; Kurtines, W.;
Perez- Vidal, A.; and Hervis, O. Bicultural ef-
fectiveness training: A treatment intervention
for enhancing intercultural adjustment. Hisp
J Behav Sci 6:317-344, 1984.
Telch, M.J.; Killen, J.D.; McAlister, A.L.; Perry,
C.L.; and Maccoby, N. Long-term followup
of a pilot project on smoking prevention with
adolescents. J Behav Med 5:1-7,1982.
Webster-Stratton, C. Randomized trial of two
parent training programs for families with
conduct-disordered children. J Consult Clin
Psychol 52:666-678, 1984.
Webster-Stratton, C. Enhancing the effectiveness
of self-administered videotape parent train-
ing for families with conduct problem chil-
dren. J Abnorm Child Psychol 18:479-492,
1990.
Webster-Stratton, C, and Herbert, M. What re-
ally happens in parent training? Behav Mod
17:407-456, 1993.
Advances in Family-Based Interventions 99
Webster-Stratton, C; Kolpacoff, M.; and West, D.J., and Farrington, D.P. Who Becomes
Hollingsworth, T. Self-administered video- Delinquent? New York: Crane, Russak, 1973.
tape therapy for families with conduct- „ri TT „ . , , ., ,
, , , %\ _ . ., Wilson, H. Parental supervision: A neglected as-
problem children: Comparison with two cost- . £ , \. n T „ . . , ~n ~~~
rr . , pect ol delinquency. Br J Cnminol 20:203-
errective treatments and a control group. ~,,, loon
J Consult Clin Psychol 56(4):558-566, 1988.
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).
3Dr. 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).
References
Achenbach, T.M. Teacher 's Report Form (TRF).
Burlington, VT: Center for Children, Youth,
and Families, University of Vermont, 1991.
Achenbach, T.M., and Edelbrock, C. Child Be-
havior Checklist (CBCL). Center for Children,
Youth, and Families. Burlington, VT: Univer-
sity of Vermont, 1988.
Achenbach, T.M., and Howell, C.T Are Ameri-
can children's problems getting worse? A 13-
year comparison. J Am Acad Child Adolesc
Psychiatry 32:1145-1154, 1993.
Aiken, L.; Stein, J.; and Bentler, P. Structural
equation analysis of clinical subpopulation
differences and comparative treatment out-
comes: Characterizing the daily lives of drug
addicts. J Consult Clin Psychol 62(3):488-
499, 1994.
Aktan, G. Organizational framework for a sub-
stance use prevention program. Int J Addict
30: 185-201, 1995.
Aktan, G.; Kumpfer, K.L.; and Turner, C. Effec-
tiveness of a family skills training program
for substance abuse prevention with inner-city
African-American families. Int J Addict
31:158-175, 1996.
Apsler, R. Evaluating the cost-effectiveness of
drug abuse treatment services. In: Cartwright,
W.S, and Kaple, J.M., eds. Economic Costs,
Cost-Effectiveness, Financing, and Commu-
nity-Based Drug Treatment. National Institute
on Drug Abuse Research Monograph 113.
Department of Health and Human Services
Pub. No. (ADM)9 1-1823. Washington DC:
Supt. of Docs., U.S. Govt. Print. Off., 1991.
Ary, D.; Duncan, T; Duncan, S.; and Hops, H. A
Developmental Model of Adolescent Problem
Behavior. Unpublished. Oregon Research In-
stitute, Oregon, 1996.
Bandura, A. Social Foundations of Thought and
Action: A Social Cognitive Theory.
Englewood Cliffs, NJ: Prentice-Hall, 1986.
Barkeley, R.A. What is the role of group train-
ing in the treatment of ADD children? J Child
Contemp Soc 49(8):599-608, 1986.
Bavolek, S. Adult-Adolescent Parenting Inven-
tory (AAPI). Park City, UT: Family Nurtur-
ing Center, 1985.
Bavolek, S.J.; Comstock, CM.; and McLaughlin,
J. A. "The Nurturing Program: A Validated Ap-
proach to Reducing Dysfunctional Family In-
teractions." Final report, Grant No.
1R01MH34862. Rockville, MD: National
Institute of Mental Health, 1983.
Beck, A.T.; Ward, C.H.; Mendelson, M; Mack,
J.; and Erbaugh, J. An inventory measuring
depression. Arch Gen Psychol 4:561-571,
1961.
Bierman, K.L.; Greenberg, M.T.; and the Con-
duct Problems Prevention Research Group.
Social skill training in the FAST Track pro-
gram. In: Peters, R.D., and McMahon, R.J.,
eds. Prevention and Early Intervention:
Childhood Disorders, Substance Abuse and
Delinquency. Thousand Oaks, CA: Sage,
1996.
Bowlby, J. Attachment and Loss. 2d ed. New
York: Basic Books, 1982.
Brook, J.S.; Brook, D.W.; Gordon, A.S.;
Whiteman, M.; and Cohen, P. The psychoso-
cial etiology of adolescent drug use: A family
interactional approach. Genet Soc Gen
Psychol Monogr 116(2): 11 1-267, 1990.
Brook, J.S.; Cohen, P.; Whiteman, M.; and Gor-
don, A.S. Psychosocial risk factors in the tran-
sition from moderate to heavy use or abuse
of drugs. In: Glantz, M.D., and Pickens, R.,
116 National Conference on Drug Abuse Prevention Research
eds. Vulnerability to Drug Abuse. Washing-
ton, DC: American Psychological Associa-
tion, 1992.
Bry, B.H. Empirical foundations of family-based
approaches to adolescent substance abuse. In:
Glynn, T.J.; Leukefeld, C.G.; and Ludford,
J. P., eds. Preventing Adolescent Drug Abuse:
Intervention Strategies. National Institute on
Drug Abuse Research Monograph 47. DHHS
Pub. No. (ADM)83-1280. Washington, DC:
Supt. of Docs., U.S. Govt. Print. Off., 1983.
Bry, B.H. "Parenting Practices That Reduce Sub-
stance Abuse Risk: Challenges for Prevention
Research." Paper presented at the National In-
stitute on Drug Abuse Family Research Sym-
posium, Gaithersburg, MD, 1996.
Bry, B.H.; Catalano, R.F.; Kumpfer, K.L.;
Lochman, J.E.; and Szapocznik, J. Scientific
findings from family prevention intervention
research. In: Ashery, R.; Kumpfer, K.L.; and
Robertson, E., eds. Drug Abuse Prevention
Through Family Interventions. National In-
stitute on Drug Abuse Research Monograph
177. U.S. Department of Health and Human
Services, National Institutes of Health, Na-
tional Institute on Drug Abuse, in press.
Bry, B.H.; McKeon, P.; and Pandina, RJ. Extent
of drug use as a function of number of risk
factors. J Abnorm Psychol 91:273-279, 1982.
Catalano, R.F.; Haggerty, K.P.; Gainey, R.R.; and
Hoppe, M.J. Reducing parental risk factors
for children's substance misuse: Preliminary
outcomes with opiate-addicted parents. Sub-
stance Use Misuse 32(6):699-721, 1997.
Center for Substance Abuse Prevention. Signs
of Effectiveness in Preventing Alcohol and
Other Drug Problems. Washington. DC: Supt.
of Docs., U.S. Govt. Print. Off., 1993.
Center for Substance Abuse Prevention. Fam-
ily-Centered Approaches To Prevent Alcohol,
Tobacco, and Other Drug Use Among Chil-
dren. Rockville, MD: Center for Substance
Abuse Prevention, Division of State Preven-
tion Systems, 1995.
Center for Substance Abuse Prevention. Preven-
tion Enhancement Protocol System (PEPS).
DHHS Pub. No. (SMA) 3224-FY98. U.S.
Department of Health and Human Services,
Substance Abuse and Mental Health Services
Administration, 1998.
Cook, T.D., and Campbell, D.T. Quasi-Experi-
mentation: Design and Analysis Issues in
Field Settings. Chicago: Rand-McNally,
1979.
Coombs, R.H.; Paulson, M.J.; and Richardson,
M. A. Peer vs. parental influence in substance
use among Hispanic and Anglo children and
adolescents./ Youth Adolesc 20:73-88, 1991.
Cowen, E.L. Parent Attitude Test (PAT). Roch-
ester, NY: Department of Psychology, Uni-
versity of Rochester, 1968.
Dadds, M.R.; Sanders, M.R.; Morrison, M.; and
Rebgetz, M. Childhood depression and con-
duct disorder: II. An analysis of family inter-
action patterns in the home. J Abnorm Psychol
101:505-513, 1992.
DeMarsh, J.P., and Kumpfer, K.L. Family-ori-
ented interventions for the prevention of
chemical dependency in children and adoles-
cents. In: Griswold-Ezekoye, S.; Kumpfer,
K.L.; and Bukoski, W., eds. Childhood and
Chemical Abuse: Prevention and Interven-
tion. New York: Haworth Press, 1986.
Derogatis, L.R., and Lazarus, L. SCL-90-R, Brief
Symptom Inventory and matching clinical rat-
ing scales. In: Maruish, M.E., ed. The Use of
Psychological Testing for Treatment, Plan-
ning, and Outcome Assessment. Hillsdale, NJ:
Lawrence Erlbaum Associates, Inc., 1994.
Dishion, T.J. "Advances in Family-Based Inter-
ventions to Adolescent Drug Abuse Preven-
tion." Paper presented at the National
Conference on Drug Abuse Prevention Re-
search, Washington, DC, September 1996.
Effectiveness of a Culturally Tailored Substance Abuse Program 117
Dishion, T.J., and Andrews, D.W. Preventing
escalation in problem behaviors with high-
risk young adolescents: Immediate and 1-year
outcomes. J Consult Clin Psychol 63:538-
548, 1995.
Dishion, T.J.; French, D.; and Patterson, G.R. The
development and ecology of antisocial behav-
ior. In: Cicchetti, D., and Cohen, D., eds.
Manual of Developmental Psychopathology:
Vol. 2. Risk, Disorder, and Adaptation. New
York: John Wiley & Sons, 1995.
Dunst, C.J. Implications of risk and opportunity
factors for assessment and intervention prac-
tices. Top Early Childh Spec Educ 13:143-
153, 1994.
Dunst, C. "Risk and Opportunity Factors Influ-
encing Child and Family Behavior and De-
velopment." Paper presented at the Fourth
National Early Intervention Meeting,
Coimbra, Portugal, June 1995.
Dunst, C.J., and Trivette, CM. Methodological
considerations and strategies for studying the
long-term effects of early intervention. In:
Friedman, S.L., and Haywood, H.C., eds. De-
velopmental Follow -Up: Concepts, Domains,
and Methods. San Diego, CA: Academic
Press, 1994.
Egeland, B., andErickson, M.F Psychologically
unavailable caregiving: The effects on devel-
opment of young children and the implica-
tions for intervention. In: Brassard, M.; Hart,
S.; and Germain, B., eds. Psychological Mal-
treatment of Children and Youth. New York:
Pergamon Press, 1987.
Egeland, B., and Erickson, M.F. Rising above
the past: Strategies for helping new mothers
break the cycle of abuse and neglect. Zero to
Three ll(2):29-35, 1990.
Forehand, R.L., and McMahon, R.J. Helping the
Noncompliant Child: A Clinician 's Guide to
Parent Training. New York: Guilford Press,
1981.253 pp.
French, M.T.; Rachal, J.V.; and Hubbard, R.L.
Conceptual framework for estimating the so-
cial cost of drug abuse. J Health Soc Policy
2:1-22, 1991.
French, M.T., and Zarkin, G.A. Effects of drug
abuse treatment on legal and illicit earnings.
Contemp Policy Issues 10:98-109, 1992.
Gainey, R.R.; Catalano, R.F.; Haggerty, K.P; and
Hoppe, M.J. Deviance among the children of
heroin addicts in treatment: Impact of parents
and peers. Deviant Behav 18(2): 143-159,
1997.
Goplerud, E., ed. Breaking New Ground for Youth
at Risk: Program Summaries. Washington,
DC: Supt. of Docs., U.S. Govt. Print. Off.,
1990.
Gordon, R. An operational classification of dis-
ease prevention. In: Steinberg, J. A., and
Silverman, M.M., eds. Preventing Mental
Disorders. Rockville, MD: U.S. Department
of Health and Human Services, 1987.
Gottfredson, G.D. An empirical test of school-
based environmental and individual interven-
tions to reduce the risk of delinquent behavior.
Criminology 24(4):705-731, 1986.
Gottfredson, G.D. Peer group interventions to
reduce the risk of delinquent behavior: A se-
lective review and a new evaluation. Crimi-
nology 25(3):67 '1-7 '14, 1987.
Greenwald, P., and Cullen, J.W. The new em-
phasis in cancer control. JNCI 74(3):543-55 1 ,
1985.
Greenwood, P.; Rydell, C; Abrahams, A.;
Caulkins, J.; Chiesa, J.; Model, K.; and Klein,
S. Diverting Children From a Life of Crime:
Measuring Costs and Benefits. Santa Monica,
CA: Rand, 1994.
Haggerty, K.P.; Mills, E.; and Catalano, R.F.
"Focus on Families: Parent Training Curricu-
lum." Social Development Research Group,
Seattle, WA, 1991.
Hans, S. Diagnosis in etiologic and epidemio-
logic studies. In: Jones, C, and De La Rosa,
M., eds. National Institute on Drug Abuse
Technical Review: Methodological Issues:
Etiology and Consequences of Drug Abuse
Among Women. Silver Spring, MD: National
Institute on Drug Abuse, 1995.
118 National Conference on Drug Abuse Prevention Research
Hansen, W.B.; Graham, J.W.; Sobel, J.L.;
Shelton, D.R.; Flay, B.R.; and Johnson, C.A.
The consistency of peer and parent influences
on tobacco, alcohol, and marijuana use among
young adolescents. J Behav Med 10:559-579,
1987.
Harrison, R.S., and Proskauer, S. "The Impact
of Family Skills Training on Children at Risk
for Substance Abuse and Their Families: A
5-Year Evaluation." Unpublished manuscript,
1995.
Harrison, S. "Evaluation Report on Utah CSAP/
CYAP Project." Submitted to the Utah State
Division of Substance Abuse. Social Research
Institute, University of Utah, Salt Lake City,
UT, 1994.
Harrison, S.; Proskauer, S.; and Kumpfer, K.L.
"Final Evaluation Report on Utah CSAP/
CYAP Project." Submitted to the Utah State
Division of Substance Abuse. Social Research
Institute, University of Utah, Salt Lake City,
UT, 1995.
Hawkins, J.D.; Arthur, M.W.; and Catalano, R.F
Preventing substance abuse. Crime Justice
18:197-281, 1994.
Hawkins, J.D.; Catalano, R.F, Jr.; and Associ-
ates. Communities That Care: Action for Drug
Abuse Prevention. San Francisco: Jossey-
Bass, 1992. 247 pp.
Hawkins, J.D.; Catalano, R.F; and Miller, J.Y
Risk and protective factors for alcohol and
other drug problems in adolescence and early
adulthood: Implications for substance abuse
prevention. Psychol Bull 112(1):64-105,
1992.
Henggeler, S.W., and Borduin, CM. Multi-
systemic treatment of serious juvenile offend-
ers and their families. In: Schwartz, I.M., ed.
Family and Home-Based Services. Lincoln:
University of Nebraska Press, 1995.
Hu, T.W.; McDonnell, N.S.; and Swisher, J. The
application of cost-effectiveness analysis to
the evaluation of drug abuse prevention pro-
grams: An illustration. J Drug Issues 1 1 : 125-
138, 1981.
Jansen, M.A.; Glynn, T; and Howard, J. Preven-
tion of alcohol, tobacco, and other drug abuse.
Am Behav Sci 39(7):790-801, 1996.
Johnston, L.D.; O'Malley, P.M.; and Bachman,
J.G. "Drug Use Rises Again in 1996 Among
American Teens." News release. University
of Michigan Monitoring the Future Study of
American Youth, December 1996.
Kameoka, V.A., and Lecar, S. "The Effects of a
Family-Focused Intervention on Reducing
Risk for Substance Abuse Among Asian and
Pacific-Island Youths and Families: Evalua-
tion of the Strengthening Hawaii's Families
Project." Available from the Coalition for a
Drug-Free Hawaii, University of Hawaii,
1996.
Kazdin, A.E. Treatment of conduct disorder:
Progress and directions in psychotherapy re-
search. Dev Psychopathol 5:277-310, 1993.
Kim, S.; Coletti, S.D.; Crutchfield, C.C.; Will-
iams, C; and Helper N. Benefit-cost analysis
of drug abuse prevention programs: A mac-
roscopic approach. J Drug Educ 25(2): 111-
127, 1995.
King, J.; Beals, J.; Manson, S.M.; and Trimble,
J.E. A structural equation model of factors re-
lated to substance use among American In-
dian adolescents. In: Trimble, J.E.; Bolek,
C.S.; and Niemcryk, S.J., eds. Ethnic and
Multicultural Drug Abuse: Perspectives on
Current Research. New York: Haworth Press,
1992.
Kogan, K.L., and Tyler, N.B. "Comparing Ways
of Altering Parent-Child Interaction." Wash-
ington University (Seattle) Child Develop-
ment and Mental Retardation Center, 1978.
Kristein, M.M. Economic issues in prevention.
Prev Med 6:252-264, 1997.
Kumpfer, K.L. Special populations: Etiology and
prevention of vulnerability to chemical de-
pendency in children of substance abusers. In:
Brown, B.S., and Mills, A.R., eds. Youth at
High Risk for Substance Abuse. National In-
stitute on Drug Abuse Research Monograph.
Effectiveness of a Culturally Tailored Substance Abuse Program 119
DHHS Pub. No. (ADM)90-1537. Washing-
ton, DC: Supt. of Docs., U.S. Govt. Print. Off.,
1987 (reprinted 1990).
Kumpfer, K.L. Prevention of mental disorders,
alcohol and other drug use in children and
adolescents. In: Shaffer, D.; Philips, I.; and
Enzer, N., eds. Prevention of Alcohol and
Drug Abuse: A Critical Review of Risk Fac-
tors and Prevention Strategies. Rockville,
MD: Office of Substance Abuse Prevention,
Monograph 2, 1989.
Kumpfer, K.L. How to get hard-to-reach parents
involved in parenting programs. In: Pines, D.,
ed. Parent Training Is Prevention: Prevent-
ing Alcohol and Other Drug Problems Among
Youth in the Family. DHHS Pub. No.
(ADM)91-1715. Washington, DC: Supt. of
Docs., U.S. Govt. Print. Off., 1991.
Kumpfer, K.L. "Safe Haven African American
Parenting Project: Second Year Evaluation
Report." Submitted to City of Detroit Health
Department. Salt Lake City: Health Behav-
ior Laboratory, Department of Health Educa-
tion, University of Utah, 1993.
Kumpfer, K.L. "Predictive Validity of Resilience
for Positive Life Adaptation." Paper presented
at a conference on The Role of Resilience in
Drug Abuse, Alcohol Abuse, and Mental Ill-
ness. National Institute on Drug Abuse, Wash-
ington, DC, December 5-6, 1994a.
Kumpfer, K.L. Strengthening America 's Fami-
lies: Promising Parenting and Family Strat-
egies for Delinquency Prevention: User's
Guide. Office of Juvenile Justice and Delin-
quency Prevention, U.S. Department of Jus-
tice Grant No. 87-JS-CX-K495. Silver Spring,
MD: Aspen Systems, 1994b.
Kumpfer, K.L. "National Search and Principles
of Effective Programs." Address presented at
Third National Training Conference on
Strengthening America's Families, Washing-
ton, DC, 1997.
Kumpfer, K.L. Factors and processes contribut-
ing to resilience: The resiliency framework.
In: Glantz, M.; Johnson, J.; and Huffman, L.,
eds. Resiliency and Development: Positive
Life Adaptations. New York: Plenum Press,
in press a.
Kumpfer, K.L. Selective prevention approaches
for drug use prevention: Overview of outcome
results from multi-ethnic replications of the
Strengthening Families Program. In: Ashery,
R.; Kumpfer, K.L.; and Robertson, E., eds.
Drug Abuse Prevention Through Family In-
terventions. National Institute on Drug Abuse
Research Monograph 177. U.S. Department
of Health and Human Services, National In-
stitutes of Health, National Institute on Drug
Abuse, in press b.
Kumpfer, K.L., and Alvarado, R. Strengthening
families to prevent drug use in multi-ethnic
youth. In: Botvin, G.; Schinke, S.; and
Orlandi, M., eds. Drug Abuse Prevention With
Multi-Ethnic Youth. Newbury Park, CA: Sage
Publications, 1995.
Kumpfer, K.L., and Bluth, B. Transactional par-
ent/child relationships and impact on resil-
ience for substance abuse. In: Johnson, J., and
McDuff, D.K., eds. The Chronicity of Sub-
stance Abuse. Baltimore: Harcourt, in press.
Kumpfer, K.L., and DeMarsh, J.P Family envi-
ronmental and genetic influences on
children's future chemical dependency. In:
Griswold-Ezekoye, S.; Kumpfer, K.L.; and
Bukoski, W., eds. Childhood and Chemical
Abuse: Prevention and Intervention. New
York: Haworth Press, 1986.
Kumpfer, K.L.; DeMarsh, J.P; and Child, W.
Strengthening Families Program: Children 's
Skills Training Curriculum Manual, Parent
Training Manual, Children's Skill Training
Manual, and Family Skills Training Manual
(Prevention Services to Children of Sub-
stance-Abusing Parents). Salt Lake City:
Social Research Institute, Graduate School of
Social Work, University of Utah, 1989.
Kumpfer, K.L.; Molgaard, V.; and Spoth, R. Fam-
ily interventions for the prevention of delin-
quency and drug use in special populations.
In: Peters, R., and McMahon, R., eds. Pro-
ceedings of the 1994 Banff International Con-
ference. Thousand Oaks, CA: Sage Pub-
lications, 1996.
120 National Conference on Drug Abuse Prevention Research
Kumpfer, K.L., and Turner, C.W. The social ecol-
ogy model of adolescent substance abuse: Im-
plications for prevention. Int J Addict
25(4A):435-463, 1990-1991.
Kumpfer, K.; Wanberg, K.; and Martinez, D.
"Strengthening Families Program." Workshop
held at Second National Training Conference
on Strengthening America's Families, Snow-
bird, UT, October 12-14, 1996.
Kumpfer, K.L.; Whiteside, H.O.; and Wan-
dersman, A. Community Readiness for Drug
Abuse Prevention: Issues, Tips, and Tools. In:
Drug Abuse Prevention Package. NCADI
#PREVPK. Rockville, MD: U.S. Department
of Health and Human Services, National In-
stitutes of Health, National Institute on Drug
Abuse, 1997.
Kumpfer, K.L.; Williams, M.K.; and Baxley, G.
Selective Prevention for Children of Sub-
stance- Abusing Parents: The Strengthening
Families Program. Resource manual. In:
Drug Abuse Prevention Package. NCADI
#PPvEVPK. Rockville, MD: U.S. Department
of Health and Human Services, National In-
stitutes of Health, National Institute on Drug
Abuse, 1997.
Levine, C; Kohlberg, L.; and Hewer, A. The
current formulation of Kohlberg' s theory and
a response to critics. Hum Dev 28(2):94-100,
1985.
Lewis, R.A.; Piercy, F.P.; Sprendle, D.H.; and
Trepper, T.J. Family-based interventions for
helping drug-using adolescents. JAdolesc Res
5:82-95, 1990.
Lorion, R.P., and Ross, J.G. Programs for change:
A realistic look at the Nation's potential for
preventing substance involvement among
high-risk youth. Special Issue: Programs for
change: Office for Substance Abuse Preven-
tion demonstration models. J Community
Psychol: 3-9, 1992.
Mayer, G.R. Preventing antisocial behavior in
the schools. JAppl BehavAnal 28(4):467-478,
1995.
McDonald, L. Families together with schools.
In: Promising Programs for Safe Schools.
Washington, DC: American Psychological
Association, 1993.
McDonald, L.; Billingham, S.; Dibble, N.; Rice,
C; and Coe-Braddish, D. FAST: An innova-
tive substance abuse prevention program. Soc
WorkEduc 13(2): 118-12, 1991.
McMahon, R.J.; Slough, N.M.; and the Conduct
Problems Prevention Research Group. Fam-
ily-based intervention in the FAST Program.
In: Peters, R.D., and McMahon, R.J., eds. Pre-
vention and Early Intervention: Childhood
Disorders, Substance Abuse and Delinquency.
Thousand Oaks, CA: Sage, 1996.
McMahon, R.J.; Tiedemann, G.L.; Forehand, R.;
and Griest, D.L. Parental satisfaction with par-
ent training to modify child noncompliance.
Behav Ther 15:295-303, 1993.
Millard, J. "Effectiveness of Parent Training in
Schools." Doctoral dissertation. University of
Utah, 1993.
Mitchell, A.; Weiss, H.; and Schultz, T. "Evalu-
ating education reform: Early childhood edu-
cation. A review of research on early
education, family support and parent educa-
tion, and collaboration." Submitted to Office
of Educational Research and Improvement,
U.S. Department of Education, 1995.
Molgaard, V.; Kumpfer, K.L.; and Spoth, R. The
Iowa Strengthening Families Program for Pre
and Early Teens. Ames, IA: Iowa State Uni-
versity, 1994.
Moos, R.H. Family Environment Scale. Palo
Alto, CA: Consulting Psychologist Press, Inc.,
1974.
Mrazek, P.J., and Haggerty, R.J., eds. Reducing
the Risk for Mental Disorders: Frontiers for
Preventive Intervention Research. Washing-
ton, DC: National Academy Press for the In-
stitute of Medicine, Committee on Prevention
of Mental Disorders, 1994.
National Institute on Drug Abuse. Coming To-
gether on Prevention. 27 min. U.S. Depart-
ment of Health and Human Services, National
Institutes of Health, National Institute on Drug
Abuse, 1994, Videotape.
National Institute on Drug Abuse. Drug Abuse
Prevention Package (four manuscripts on pre-
vention). NCADI #PREVPK. Rockville, MD:
Effectiveness of a Culturally Tailored Substance Abuse Program 121
U.S. Department of Health and Human Serv-
ices, National Institutes of Health, National
Institute on Drug Abuse, 1997.
Newcomb, M.D. Understanding the multidimen-
sional nature of drug use and abuse: The role
of consumption, risk factors, and protective
factors. In: Glantz, M.D., and Pickens, R., eds.
Vulnerability to Drug Abuse. Washington,
DC: American Psychological Association,
1992.
Newcomb, M.D. Drug use etiology among eth-
nic minority adolescents: Risk and protective
factors. In: Botvin, G.; Shinke, S.; and
Orlandi, M.A., eds. Drug Abuse Prevention
With Multiethnic Youth. Thousand Oaks, CA:
Sage, 1995.
Newcomb, M.D., and Bentler, P.M. Drug use,
educational aspirations, and workforce in-
volvement: The transition from adolescence
to young adulthood. Am J Community Psychol
14(3):303-321, 1986.
Newcomb, M.D.; Maddahian, E.; and Bentler,
P.M. Risk factors for drug use among adoles-
cents: Concurrent and longitudinal analyses.
Am J Public Health 76:525-531, 1986.
Oetting, E.R. Planning programs for prevention
of deviant behavior: A psychosocial model.
In: Trimble, J.E.; Bolek, C.E.; and Niemcryk,
S.J., eds. Ethnic and Multicultural Drug Use:
Perspectives on Current Research. New York:
Haworth Press, 1992.
Oetting, E.R., and Beauvais, F. Peer cluster
theory, socialization characteristics, and ado-
lescent drug use: A path analysis. J Counsel
Psychol 34(2):205-2l3, 1987.
Oetting, E.R.; Swaim, R.C.; Edwards, R.W.; and
Beauvais, F. Indian and Anglo adolescent al-
cohol use and emotional distress: Path mod-
els. Am J Drug Alcohol Abuse 15(2): 153-172,
1989.
Parsons, B., and Alexander, J. "The Functional
Family Program." Workshop presented at
Third National Training Conference on
Strengthening America's Families. Washing-
ton, DC, 1997.
Patterson, G.R. Families: Applications of Social
Learning to Family Life (rev. ed.). Cham-
paign, IL: Research Press, 1975.
Patterson, G.R. Living With Children: New Meth-
ods for Parents and Teachers. Champaign, IL:
Research Press, 1976.
Patterson, G.R.; Dishion, T.J.; and Chamberlain,
P. Outcomes and methodological issues re-
lating to treatment of antisocial children. In:
Giles, T.R., ed. Handbook of Effective Psy-
chotherapy. New York: Plenum, 1993.
Pentz, M. A. Directions in future research in drug
abuse prevention. Prev Med 23:646-652,
1993.
Plotnick, R.D. Applying benefit-cost analysis to
substance abuse prevention programs. Int J
Addict 29:339-359, 1994.
Radloff, L.S. The CES-D Scale: A self-report
depression scale for research in the general
population. Appl Psychol Meas 1(3):385-401,
1977.
Rice, D.P.; Kellam, S.; and Miller, L.S. Economic
cost of drug abuse. In: Cartwright, W.S., and
Kaple, J.M., eds. Economic Cost, Cost- Effec-
tiveness, Financing, and Community-Based
Drug Treatment. National Institute on Drug
Abuse Research Monograph 113. DHHS Pub.
No. (ADM)91-1823. Washington, DC: Supt.
of Docs., U.S. Govt. Print. Off., 1991.
Russell, L.B. Is Prevention Better Than Cure?
Washington, DC: Brookings, 1986.
Rutter, M. Psychosocial resilience and protec-
tive mechanisms. Am J Orthopsychiatry
57(3): 316-331, 1987.
Rutter, M. Resilience: Some conceptual consid-
erations. J Adolesc Health 14:626-631, 1993.
Sameroff, A.; Seifer, R.; Barocas, R.; Zax, M.;
and Greenspan, A. Intelligence quotient scores
of 4-year-old children: Social environmental
risk factors. Pediatrics 79:343-350, 1987.
122 National Conference on Drug Abuse Prevention Research
Sherwood, A., and Harrison, S. Final report on
Utah's CYAP Project. Report to CSAP: State
Division of Substance Abuse, Salt Lake City,
UT, 1996.
Spivack, G., and Shure, M. Interpersonal cogni-
tive problemsolving and primary prevention:
Programming for preschool and kindergarten
children. J Clin Child Psychol 8(2):89-94,
1979.
Spoth, R. "Results From Iowa Strengthening
Families Program for Drug Use." Paper pre-
sented to the Society for Prevention Research
Annual Conference, Baltimore, MD, 1997.
Spoth, R. Family-focused preventive interven-
tion research: A pragmatic perspective on is-
sues and future directions. In: Ashery, R.;
Kumpfer, K.L.; and Robertson, E., eds., Drug
Abuse Prevention Through Family Interven-
tions. National Institute on Drug Abuse Re-
search Monograph 177. U.S. Department of
Health and Human Services, National Insti-
tutes of Health, National Institute on Drug
Abuse, in press.
Spoth, R.; Redmond, C; Haggerty, K.; and Ward,
T. A controlled parenting skills outcome study
examining individual difference and atten-
dance effects. J Marriage Fam 57:449-464,
1995.
Spoth, R.; Redmond, C; Hockaday, C; and Shin,
C. Barriers to participation in family skills
preventive interventions and their evaluations:
A replication and extension. Fam Relations
45:247-254, 1996.
Spoth, R.; Redmond, C; and Shin, C. Direct and
indirect latent variable parenting outcomes of
two universal family-focused prevention
interventions: Extending a public health-
oriented research base. J Consult Clin
Psychol, in press.
Swaim, R.C.; Oetting, E.R.; Edwards, R.W.; and
Beauvais, F Links from emotional distress to
adolescent drug use: A path model. J Consult
Clin Psychol 57(2):227-231, 1989.
Szapocznik, J. "Cultural Competency and Pro-
gram Implementation." Keynote Address pre-
sented at Third National Training Conference
on Strengthening America's Families. Wash-
ington, DC, 1997.
Szapocznik, J., and Kurtines, W.M. Break-
throughs in Family Therapy With Drug-Abus-
ing and Problem Youth. New York: Springer,
1989.
Szapocznik, J.; Perez-Vidal, A.; Brickman, A.L.;
Foote, F.H.; Santisteban, D.; Hervis, O.; and
Kurtines, W.M. Engaging adolescent drug
abusers and their families in treatment: A stra-
tegic structural systems approach. J Consult
Clin Psychol 56(4):552-557, 1988.
Szapocznik, J.; Santisteban, D.; Rio, A.; Perez-
Vidal, A.; and Kurtines, W.M. Family effec-
tiveness training (FET) for Hispanic families:
Strategic structural systems intervention for
the prevention of drug abuse. In: Lefley, H.P,
and Pedersen, P.B., eds. Cross Cultural Train-
ing for Mental Professionals. Springfield, IL:
Charles C. Thomas, 1985.
Wanberg, K., and Nyholm, S., evaluators. Grant
No. H-86-SP-03846. Final Project Report.
Description and Evaluation of the Denver
Area Youth Services La Familia Community
Drug and Alcohol Prevention Programs:
Strengthening Families Program and Basic
Prevention Program. June 1998.
Webster-Stratton, C. Videotape modeling: A
method of parent education. J Clin Child
Psychol 10:93-97, 1981.
Webster-Stratton, C. Long-term effects of a vid-
eotape modeling parent education program:
Comparison of immediate and 1-year-
followup results. Behav Ther 13:702-714,
1982.
Webster-Stratton, C; Kolpacoff, M.; and
Hollingsworth, T. Self-administered video-
tape therapy for families with conduct-
problem children: Comparison with two
Effectiveness of a Culturally Tailored Substance Abuse Program 123
cost-effective treatments and a control group. Yoshikawa, H. Prevention as cumulative protec-
J Consult Clin Psychol 56(4):558-566, 1988. tion: Effects of early family support and edu-
. , cation on chronic delinquency and its risks.
Werner, E.E. Resilient offspring or alcoholics: A , , M J
i ■+ a- t * a f u-Jf- 10 re, a Psychol Bull U5(l):2&-54, 1994.
longitudinal study from birth to age 1 8. J Stud J '
Alcohol 47:34-40, 1986.
Werner, E.E., and Smith, R.S. Overcoming the
Odds: High Risk Children From Birth to
Adulthood. Ithaca, NY: Cornell University
Press, 1992.
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 2V2 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 Prevention4
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
4Elaine 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 2V2 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. Copple5
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 2V2-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 0 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
Live Music Archive
Librivox Free Audio
Metropolitan Museum
Cleveland Museum of Art
Internet Arcade
Console Living Room
Books to Borrow
Open Library
TV News
Understanding 9/11