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An Intervention Program To Arrest Drug Abuse Among Adolescents And Young Adults

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Synopsis

Drug abuse by teenagers and young adults is showing an increasing trend over the last decade. Nearly 25% of young adults, in the age group 18-25 years, are current users of an illicit substance, implying that they have used it at least once during the past one month. An effective intervention is required to arrest this alarming upward trend and this paper presents evidence for and against several such intervention programs at various school levels. Based on a literature review, it proposes the implementation of a modified version of the popular program “Drug Abuse Resistance Education” (DARE). It describes the implementation of such a program in a classroom at the high school level. IntroductionThe purpose of this paper is to provide a comprehensive evidence-based review of a problem that afflicts an increasingly larger segment of the American population and to suggest an appropriate intervention strategy. The problem is the increasing trend of substance abuse among adolescents/teenagers (age group 12-17 years) and young adults (age group 18-25 years), with consequences at personal as well as community levels. According to the National Survey on Drug Use and Health, 2017, carried out by the Substance Abuse and Mental Health Services Administration (SAMHSA), approximately 30. 5 million people (11. 2% of the population) aged 12 years or more are current users of an illicit drug (have used it at least once in the past 30 days). Even more alarmingly, the proportion of young adults who are current users of an illicit drug has increased from 16. 3% as of 2007 to 24. 2% as of 2017 while the proportion of teenagers has increased from 6. 7% to 7. 9% over the same period.

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Marijuana and misused prescription pain-relieving drugs were identified by the report as the primary illicit substances, followed by cocaine and hallucinogens. A number of biological and psychological factors may contribute towards predisposing adolescents and young adults to substance abuse. Sensitivity to the pharmacological effects of drugs having the potential for abuse and dependence, for example, has been found to be lower during adolescence compared to adulthood. As a result, larger quantities are consumed to achieve the desired effect, which leads to acute and chronic tolerance and results in substance dependence. The problem is compounded by the fact that only 10% of adolescents and young adults, who meet the criteria for abuse and dependence, receive some form of intervention or treatment. Substance abuse has a number of ill-effects, including the onset of major depressive episodes, some form of serious mental illness, poor educational outcomes, and involvement in criminal activities. Physical ailments include predisposition towards cardiac diseases and some forms of carcinoma, increased blood pressure, diseases of the lung and digestive organs, hepatitis, and other serious afflictions. It has, therefore, become imperative to review existing evidence-based intervention strategies/programs and to create an intervention plan that can effectively counteract this growing problem.

Description of the intervention program identified as having the best effects

The intervention program identified to mitigate the problem of growing substance abuse among teenagers and young adults is the updated Drug Abuse Resistance Education, popularly known by its acronym DARE. It is a macro-level target program employed for the prevention of substance abuse as well as other social problems that students in these age categories typically face, such as gang membership and violence. The program was instituted in 1983 by Daryl Gates, who was the chief of the Los Angeles Police Department at that time. It was implemented in close cooperation with the Los Angeles Unified School District as part of the “War on Drugs” campaign conducted by the Federal government.

Since its implementation and subsequent evidence-based modification, it has become very popular and is now conducted in conjunction with local police departments throughout the nation. It has even been used in several other countries and more than 36 million children worldwide have participated in the program as of 2017. The implementation of DARE is based on a simple premise – police officers are required to visit schools located within their precincts and deliver lectures to students at various grade levels. The lectures are aimed at improving the self-esteem and self-confidence of the young attendees so that they are able to resist the temptation of drugs and other illicit substances more effectively. The officers are trained to provide lectures at various levels, including elementary, junior and senior high school, while its core curriculum is offered to students in the fifth and sixth grades of elementary school. This core curriculum consists of 17 lectures, delivered once a week, and uses a number of pedagogical methods such as question-and-answer sessions, role-playing, written exercises, and group discussions. Recognizing the peer pressure that senior students face, the senior high curriculum also emphasizes everyday choices and situations confronting them; and a DARE officer and a school teacher use the method of team teaching to illustrate to the students how to manage anger and how to avoid high-risk choices. Senior students are encouraged to interact with DARE officers and to ask them questions on their own assumptions about drug use, rather than simply listening to lectures.

Search Method and Criteria

Search for intervention programs and policies was conducted among reputed journals. In addition to Google search, a number of online peer-reviewed article databases were used, including MEDLINE, the Cochrane Database of Systematic Reviews, ERIC, PsycINFO, and others. The research period was between 1990 and 2018 (since DARE was initiated in 1983). A number of search keywords and search terms (Boolean search) were used, such as “DARE assessment”, “substance abuse among adolescents”, “prevention of drug use in school”, “school-based intervention programs”, etc. A few inclusion and exclusion criteria were used while selecting papers for review, and search strategies were slightly modified for each database as appropriate. Studies describing abuse of alcohol and tobacco were excluded, and so were those describing intervention programs for individuals outside the age group of interest (12 to 25 years). Reviews of programs that did not present results or evidence in favor of or against such programs were also excluded. On the other hand, papers that were included presented primary results from one or more intervention programs or were meta-analyses of several programs, performed either through longitudinal or cross-sectional data analysis. Experimental studies that used methods of randomization, allocation concealment, blinding, etc. were included in the review. Additionally, the papers were checked for any identifiable bias or incorrect methodology; reported effect sizes were ascertained wherever possible. The selection process finally yielded 12-15 good quality research papers, based on which this paper is written.

Results

A search of literature and websites yielded a number of alternative policies and interventions aimed at preventing teenagers and young adults from becoming addicted to illicit substances. The National Institute of Drug Abuse (NIDA), for example, listed several research-based intervention programs in its “Red Book” that can be implemented to significantly reduce early use of alcohol and drugs based on risk factors and protective factors. An example of such a program at the elementary school is Promoting Alternative Thinking Strategies (PATHS); an example at the middle school level is the Life Skills Training (LST) Program, and an example at the high school level is the Project ALERT Plus. While these may be characterized as universal programs (attended by all students across the nation), more selective programs aimed at specific groups (such as students whose parents are being treated for addiction) have also been designed; an example of such a program is Focus on Families (FOF), received by parents addicted to methadone and their children who are in elementary school.

This section of the paper compares some of these programs with DARE in terms of methodologies, results, and evidence of effectiveness or otherwise. The effectiveness of DARE has been analyzed by numerous researchers and government agencies. Ennett et al. (1994) carried out a meta-analysis of the program using both published and reliable unpublished data from the prior decade and used the criterion of effect size to compare the effectiveness of the program across studies. They selected studies that used a control or comparison group, implemented a pretest-posttest design, and operationalized their quantitative outcome constructs using a procedure with high reliability and validity. The authors found that the effect size of the core education program of DARE on drug use was small, possibly because only a small percentage of elementary school students (towards whom the core curriculum is targeted) use drugs. The effects of the program on knowledge acquired during class sessions as well as attitudes and skills were found to be larger, particularly in comparison with some of the non-interactive programs that the authors evaluated.

Another effectiveness study of the program using 5-year follow-up results was conducted by Clyton, Cattarello, & Johnstone (1996). They noted that the principal purpose of the DARE curriculum was to combine aspects of information and education about drugs and their effects, increase peer pressure resistance skills and decision-making skills, create more accurate perceptions of the numbers and percentage of same-age peers who are using drugs, enhance self-esteem, recognize one’s responsibility for safety, and avoid gang involvement. They also found that while statistically significant effects were obtained for some outcomes at the midpoint of the five-year study (at the 7th-grade level), overall trajectories of growth in drug use were similar for students in both intervention and comparison conditions. They found that the program had a greater impact on attitudes towards drug than on actual drug usage in the longer term, while statistically significant shorter-term impacts of the intervention were obtained with respect to some measures of drug attitudes, peer pressure resistance, and subjects’ estimates of drug use by their peers. As a result of these findings, the authors recommended that such intervention programs may be more successful when targeted at the individual level or for small groups of students, rather than for entire classrooms or schools. Recognizing these shortcomings and other criticisms in methodology and implementation, the DARE program was altered in accordance with findings from evidence-based research, and a new curriculum – “keepin’ it REAL” – was introduced for elementary and middle schools.

According to Hecht, Colby, & Miller-Day (2010), this new curriculum was more effective in diffusion and dissemination of drug prevention information, thereby making it more effective in terms of outcome; as a result, it was also designated as “evidence-based” by the National Registry of Evidence-based Programs and Practices. Similarly, a synthesis of empirical evidence by Singh et al. (2011) indicated that the new curriculum was more effective than the earlier one and there was evidence that it was able to effectively influence normative beliefs and attitudes among students about drug use, as well as increase their skills in refusing the use of illicit substances. Students who undertook the “keepin’ it REAL” course were found to be more likely to have a long-term anti-drug attitude and were likely to sample an illicit drug less often than those in a control group. In addition, the program was shown to reduce incidents of drug use among a sample of 1300 students by as much as 72% compared to those in the control group.

A systematic review by Caputi & McLellan (2017) also found evidence of the effectiveness of the new curriculum, especially at the middle and high school levels and for Hispanic and Black students who came from a predominantly low-income background. The authors, however, found notable variability in implementations of the program at different school levels and suggested that it may not be suitable for a Pan-American implementation. Compared to the DARE program and its modification, some of the other universal programs have either been more or less effective in reducing substance intake rates among adolescents and teenagers; however, almost none has been as effective in terms of attitude and knowledge outcomes. For example, an assessment of the PATHS program using a randomized trial methodology by Crean & Johnson (2013) revealed the program’s effectiveness in reducing student aggression but was unclear about whether such behavioral change lasted in the long run.

Another assessment by Curtis & Norgate (2007) using a pretest-posttest approach indicated that students in the intervention group exhibited significant improvements in terms of emotional difficulties and behavioral difficulties, but did not improve in terms of self-control when it came to withstanding peer pressure. Another such program, Project ALERT (implemented in high schools) was evaluated by Jackson et al. (2012) using the randomized control trial method. The authors found that the program was effective in the short term in terms of reduced usage of cannabis and alcohol, but its effects did not last in the long run (6 years or more). The intervention was, therefore, found not to be effective once the classroom lessons stopped. According to Ellickson et al. (2009), the project reduced the likelihood of drug abuse among young adults irrespective of gender by helping them understand the benefits of abstention from illicit substances, but the motivational impact of the program did not have a long-term effect. The study adopted a randomized controlled trial methodology and focused on the classroom-based drugs-prevention program that imparted knowledge about and consequence of drug use; as well as how to reduce barriers to drug resistance.

Another systematic review of the program and a few others by Hale, Fitzgerald-Yau, & Viner (2014) found small effect sizes for almost all the universal intervention programs in terms of reduced substance abuse and reduced health risks. The Lions-Quest Skills for Adolescence program is also aimed at the high school level, and this was evaluated by Flynn, Falco, & Hocini (2016). After systematically reviewing several randomized control trials involving the implementation of the program, they found significant differences in substance abuse related behavior in only three of the studies. In the case of the program which showed positive results, they found that it was able to increase normative and resistance skills through imparting of social skills knowledge. The authors presented evidence that both lifetime and recent marijuana uses were lower for those who undertook the program, compared to the control group. However, the effect size was found to be low. The overall survey seems to indicate that no single program can be said to have performed unequivocally with respect to reducing drug abuse rates among teenagers and young adults; in fact, no evidence was found for the efficacy of many of the programs. The DARE program, while not having shown high efficacy either, was more effective in changing attitudes and beliefs of its recipients, particularly at the high school level. Another interesting aspect was that the program designers substantially modified the curriculum in order to meet some of these criticisms and to make it more evidence-based. The following section describes my implementation of the program.

Intervention Plan

Based on my literature study and presentation of evidence, I chose to implement the modified DARE program. It is a universal program which is suitable for all children who are exposed to a similar set of risks and protective factors, such as those studying in a school or those belonging to a community. I chose to create an intervention plan for the high school level since research indicates that the DARE program has been most successful at this educational level. I modeled my plan on the “Keepin’ it Real” program which is at present available only for elementary and middle schools. The program will be administered by police officers in uniform, who have always been a symbol of the DARE program throughout its lifespan, in collaboration with school teachers. The essence of the program will be its broad emphasis on the development of the character traits of safety, honesty, and responsibility, rather than a narrow focus on substance abuse avoidance tactics (since this broader emphasis is also a part of the modified “Real” program). Therefore, in addition to providing motivational education on means of resisting drug abuse and deflecting peer pressure, the program will also help students develop decision-making skills and emphasize several protective factors such as impulse control, attachment to the community, academic progress, and monitoring by parents and/or community elders.

According to the literature review, the “Real” program is able to increase students’ skills in refusing the use of illicit substances; therefore, the intervention program will attempt to strengthen these protective factors and target the use of all types of illicit drugs. The program will be modified according to the demographic profile of the participating students – for example, if there is a higher proportion of Hispanic students in the school where it is to be implemented, then the program will use a dual language scheme. In order to further increase the effectiveness of the program, its content will be appropriate for students at the high school level, or grades nine and above. It will particularly emphasize family and parental bonding because drug abuse prevention, at its essence, is a family-based program.

15 July 2020

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