Anti-drug overdose?

Many school prevention programs don't help, scientists say, and may even do harm.

By Marnell Jameson

Los Angeles Times

http://www.latimes.com/features/health/la-he-drugs15may15,0,7772461.story?coll=la-home-health

May 15, 2006

LIKE millions of kids across America, ninth-grader Mariana Kouloumian was taught in elementary school not to drink or use drugs — ever. To her, the message seemed clear except for one hitch: It didn't square with what she saw in the real world, or even at home.

"When I told my parents what I learned in [school], that drinking was bad, they said they knew that, but that a drink once in a while was OK," Mariana says.

Today, at 14, the Los Angeles girl dismisses much of what she learned in the drug-education program, saying that when she's older she plans to follow the more moderate example set by her mother and father.

"My parents know how much alcohol they can handle. They only drink socially — and wouldn't drink and drive." Further, she credits her parents, not school lessons, with helping her turn down tobacco, alcohol and drugs — all of which she's been offered. "I learned what I know at home," she says. To her, the anti-drug program seemed out of touch.

Increasingly, many academic scholars and government researchers agree. They point to a growing body of evidence that supports Mariana's instincts. One-size-fits-all lessons do little to prepare kids for the real drug choices they're likely to face, these experts say. By condemning all drugs as bad — not distinguishing between legitimate medications and, in moderation, alcohol — such programs can confuse kids and ultimately cheapen their own messages.

"Oversimplification is just one reason most school-based drug-prevention programs don't work," says David Hanson, professor emeritus of sociology at the University of North Carolina at Chapel Hill, who has spent the last 30 years studying alcohol use, abuse and education. "The decisions kids face are more nuanced than most drug programs make them appear."

The few programs shown to be successful are often not the ones used in schools. In a 2002 study from the North Carolina University, researchers looked at a national sampling of drug-prevention programs at public and private schools. They found that although 82% of schools used some kind of program, only 35% of public schools and 13% of private schools were using one that researchers had found effective.

Some researchers even suggest that school drug-prevention programs could do harm, particularly to younger students. Not only might they give kids a message that's so simplistic it isn't true, but the programs can also encourage kids to view themselves as potential drug users.

They can also portray an exaggerated view of the prevalence of drugs (thereby implying use is more accepted), and, sometimes, even offer technical information that kids could use on the street.

Nonetheless, every year, U.S. schools pour millions of dollars into substance-abuse education that hasn't been shown to be effective — $750 million to $1 billion alone for DARE, or Drug Abuse Resistance Education, by far the nation's largest school-based drug-prevention program, but one that is not on federally approved lists. The 16-week curriculum brings local police officers into classrooms to give lessons and share off-the-street experiences, driving home the point that drug use is wrong.

Under the No Child Left Behind Act of 2001, which includes a component known as Safe and Drug-Free Schools, every public school is supposed to provide some kind of drug-prevention education. If the schools use federal funds for such efforts, they must use programs on the government's lists of those with "demonstrated effectiveness." Schools may use programs not on the list if they use local funds, which many choose to do.

Support for DARE, for example, is still high. The program is used in 70% of school districts, says Dale Brown, regional director of Los Angeles-based DARE America, although the Department of Education took the program off its approved list in 2001.

Richard Clayton, associate dean of research at the University of Kentucky College of Public Health, who has studied drug-education programs, says DARE, has been effective in other ways. "More kids showed up to school on DARE days and DARE had and still has the best infrastructure of any drug program. We need to fix the message, not change the messenger."

Despite the mixed track record, many parents, teachers and school administrators maintain that such programs are crucial if children are to learn to resist peer pressure down the road.

"We need to take a preventive approach and help kids as early as possible to stay away from drugs and alcohol," says Lori Vollandt, coordinator for health education programs for the Los Angeles Unified School District. "The sooner kids learn to take care of their bodies the better."

Popular, but questionable

The real worry is that the science-based research to date has found that most anti-drug education programs don't reduce the rate at which kids abuse drugs and alcohol.

According to Monitoring the Future, a study funded by the National Institute on Drug Abuse that since 1976 has been tracking illicit drug use (not including alcohol) among high schoolers, 58% of 12th-graders had used an illicit drug in 1976. Use peaked in 1980 at 68%, then dropped to a low of 40% in 1992. By 1998 it was back up to 1976 levels, and for the last few years use has dipped to around 52%.

"The trend rises and falls, and we have no clue why," Clayton says.

Drug-education advocates say the success of the programs should be measured in terms of the kids who don't use drugs — and thus don't show up in these numbers — not those who do.

Individually, some programs help; some hurt. And many simply haven't been scientifically studied, says Liz Robertson, chief of prevention for the National Institute on Drug Abuse's research branch.

DARE gets singled out because it's the biggest in the country and therefore the most studied. But many other programs are not science-based either.

In one landmark study, funded by the National Institutes of Health, University of Kentucky researchers examined DARE's effect over a five- and 10-year period. Both times, no significant differences were found between the behaviors of kids in control groups and those who had participated in DARE, says Clayton, who led the study.

In 2004, Steve West and his colleagues at Virginia Commonwealth University, in Richmond, Va., analyzed all the DARE studies done to date and published their findings in the American Journal of Public Health. "Our study," the authors wrote, "supports previous findings indicating that DARE is ineffective. This is not surprising given the substantial information developed over the past decade to that effect."

"We weren't saying the program wasn't well intentioned," says West, a professor of rehabilitation counseling. "Just that as a prevention effort, it was a huge waste of time and money. There are better programs."

Other popular, approved programs also have fared poorly. The National Institute on Drug Abuse has performed randomized controlled studies on the Families and Schools Together (FAST) program, and found it had no positive effect. The widespread Reconnecting Youth program initially proved effective, but failed to produce positive results in two independently replicated studies, says Robertson. In fact, many of those on the approved lists haven't been studied as stringently as Robertson would like.

Most drug-prevention programs don't work because they use scare tactics, Hanson says. "They tell kids things they will later find out aren't true, like alcohol is a gateway to drugs and will seduce you into trying more dangerous substances. Also, by saying all alcohol is bad, they send kids home thinking that if their parents have a glass of wine with dinner or a beer with their pizza, they are abusing drugs. If a child's father happens to tend bar, they come home and ask why he's a drug dealer. Then what happens when the child sees the off-duty DARE officer having a beer at the local bowling alley?"

Further, drug-prevention programs often make drugs sound more prevalent than they are. Studies show that when middle school students report what percentage of kids they think are using drugs, their estimates top the actual numbers.

When you give kids the true perspective, that not everyone is doing it, they don't feel as much pressure to try, Robertson says. "That's a lot more beneficial than a five-hour blitz of information that covers every drug and how they're used, and that glorifies and exaggerates them."

Some researchers and scientists worry about the harm some programs may be doing to kids. A 1998 Illinois study, for example, found that DARE inadvertently encouraged a few students to try drugs.

DARE responded to such findings by revamping, says Brown. "The program now focuses on teaching kids how to make good decisions, how to avoid drugs and violence, and how to stand up to peer pressure," he says. "There's a lot less officer lecturing and a lot more role-playing and interaction."

While the experts sort out what works and what doesn't, many worry that the effects of some of the programs could be particularly harmful to younger students. Although many prevention programs start targeting fifth-graders, others such as the widespread Red Ribbon Week are popular in kindergarten through fourth grade.

Red Ribbon Week campaigns are often loosely implemented. Schools get an information packet that they often turn over to volunteer parents who organize a program in which kids wear red ribbons and learn not to put bad stuff in their bodies — which likely wasn't on their minds in the first place.

"The harm is that kids don't need these messages yet, and by making them too simplistic, they will dismiss them when they're older and do need this message," Robertson says. She adds that these programs make kids who have never considered using drugs see themselves as potential drug users.

"We know that making kids more aware can be dangerous, especially if these are high-sensation-seeking kids," she says. "When kids are ready, they really will ask the right questions. Don't give them more information than they ask for. I don't understand people who give third-graders all the street names for drugs. Why would anyone do that?"

Others strongly disagree: "Early and often. That's our cardinal rule," says Judy Cushing, past president of the National Family Partnership, the organization that founded and oversees Red Ribbon Week. "It's never too early to tell kids what's healthy and what isn't to put in their bodies."

Parents, teachers and kids love Red Ribbon Week, she adds. "Red Ribbon stands for hope and gives kids the incentive to make healthy choices. And it's something people can wrap their arms around."

LAUSD's Vollandt also thinks that forewarned is forearmed. She advocates beginning drug-awareness programs in pre-kindergarten classes. "We shouldn't wait to introduce this education in response to an event," she says.

Many educators, officers and parents agree. LAUSD offers Too Good for Drugs in lower schools, Project Alert in middle schools and Project Toward No Drug Abuse in upper schools. They are on the U.S. Department of Education's approved list and are considered model programs by the Substance Abuse and Mental Health Services Administration, or SAMHSA. The programs stress drug resistance skills in a realistic way.

Some educators and parent groups insist that even programs not labeled as effective can work. They point to how much kids have learned about drugs by the end of the program and indications that students, parents and teachers liked it.

But the only criterion that matters, scientists counter, is behavioral change.

Tailored lesson plans

Nobody is suggesting schools cut out drug-prevention education altogether. Not only does the government mandate it, society places a moral obligation on schools to do something to prevent future drug use.

But to get the right program, school officials need to first know what their school needs, says Robertson. Not all schools warrant the same level of intervention. Some just need good universal programs in peer refusal skills. Others with a drug problem need an intensive intervention program such as Project Toward No Drug Abuse. This interactive course strives to teach high schoolers the misperceptions that may lead to substance use, how substance abuse starts and progresses, the myths and consequences of drug use, and the coping and self-control skills they'll need to refuse.

Unfortunately, Hanson says, when schools choose, they pit anecdotes against scientific research. "Often the anecdotes win," she says.

To find out whether a program is deemed worthwhile by the government or to learn more about effective interventions, parents and educators can go to the SAMHSA site, http://www.modelprograms.samhsa.gov . Other federal agencies have lists of approved programs, but SAMHSA's is the most comprehensive.

The site features the National Registry of Evidence-based Programs and Practices. These model programs have been tested in communities, schools, social service organizations and workplaces across America, and have provided proof that they have prevented or reduced substance abuse and other related high-risk behaviors. Programs are listed as either promising, meaning they have shown some positive outcomes, or effective, meaning that they have shown consistently positive outcomes.

Finally, teachers must implement the program the way it was designed. "Many teachers take a curriculum and teach only parts of it — or teach it the way they want — and the program doesn't work," Robertson says. For example, in the recent NIDA study, teachers were taught the basics of Life Skills Training, a proven, science-based program, and were then allowed to implement it as they wanted. The program failed to show a positive effect.

Drug educators also need to stop exaggerating, Hanson says. Painkillers can be appropriate, antidepressants can be beneficial, and moderate drinking can be socially acceptable. In short, he says, messages need to be nuanced to fit social norms — in other words, actual behavior.

And individual kids at risk need to be identified early. Aggressive or withdrawn youths — and those who struggle in school — are more likely to abuse drugs, research has shown. Helping them become more socially competent or overcome learning problems can go a long way toward reducing drug use.

Furthermore, the consensus among researchers is that the programs should incorporate more role-playing with peers — and less lecturing about the varieties and dangers of drugs. Most kids who experiment with drugs do so for emotional reasons, often to be accepted.

"Emotions drive most kids," Clayton says. "When working with these developing brains, prevention experts have to consider that cognitive reasons, such as the behavior is illegal and might harm your body, don't matter as much."

Regardless of which program schools ultimately choose, Hanson offers some more immediate perspective: "The overwhelming evidence supports that the modeling that happens at home will still have the greatest effect on how kids ultimately behave."