Identification of Drug Abuse Prevention Programs

Literature Review

Sections
- Introduction
- Purpose
- Types of Prevention Interventions

Part A - Universal School-Based Prevention Programs:
   - Cognitive and Affective Prevention Approaches
   - Social Influence Approaches
   - Personal and Social Skills Training
   - Youth-Led or Involvement Approaches
   - School Climate Change Approaches
   - Community Partnership Approaches
   - Family-Focuses Approaches
   - Effectiveness of Universal Approaches
   - Parent Involvement Approaches
   - General Practice in Universal Prevention Programs
   - Summary and Research and Practice Recommendations

- Part B - Selective School-Based Prevention Programs
- Part C - Indicated School-Based Prevention Programs
- Comparison of Effectiveness of Different Prevention Approaches
- Summary of Results of Effectiveness Studies
- References

Introduction

Drug use, violence, delinquency, teen pregnancy, and other problem behaviors among young people are causes for grave concern in the United States. Despite a decade of success in reducing drug use in youth, the prevention field is currently losing ground again. Five years of rising adolescent drug use (Johnston, O'Malley, & Bachman, 1996) has increased the urgency to identify successes and improve the dissemination of prevention programs that work. Although skeptics say prevention doesn't work, the research literature contains a number of research-based prevention strategies with sufficient program effectiveness in Phase III Controlled Intervention Trials to warrant dissemination (Falco, 1993; Kumpfer, 1997a; Kumpfer & Alder, 1997; National Institute on Drug Abuse [NIDA], 1997; Tobler & Stratton, 1997).

The recent, highly publicized failure of the popular Drug Abuse Resistance Education (DARE) program (Ennett, Tobler, Ringwalt, & Flewelling, 1994) has highlighted the importance of enhanced dissemination of programs that work. Hence, a major task for the prevention field and funding agencies is to improve the identification and dissemination of the most effective prevention programs to schools and communities. In the ideal model of the five phases of research proposed by Jansen, Glynn and Howard (1996), prevention programs implemented at the state and local levels should be based on tested interventions in Phase III controlled intervention trials further tested for generalizability on Phase IV. These Phase III controlled intervention trials likewise should address the most salient precursors of drug use and abuse as suggested by Phase I and II biomedical and etiological research. This logical, smooth flow of research into practice is not happening.

Major gaps are occurring in the linkage between product research and product dissemination. An ideal research-based approach flows smoothly from basic biomedical research through the five phases of research to implementation of models in nationwide prevention and health services programs (Jansen, Glynn, & Howard, 1996). This review of the research and practice literature suggests that the most commonly used programs typically are the most highly commercially marketed programs, which rarely have solid research results. Although some popular prevention programs are based on similar principles, they are generally not of equal intensity, do not control fidelity as well, or do not have well-trained implementors.

The research-based programs with effectiveness results usually are those developed and tested in federally funded Phase III clinical trials, generally by university researchers. Because few university researchers have the time or the knowledge to market their programs commercially, funding sources need to support the dissemination of research-based approaches. Practitioners also have a responsibility to question the effectiveness of the programs they are planning to implement and to select a prevention program by matching the prevention intervention to the risk characteristics of the proposed participants.

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Purpose

This paper discusses what we have learned about the most effective school, community, and family-focused strategies for altering individual dispositions toward drug abuse. In this paper, the term effective is used to describe research-based drug abuse prevention programs that have positive outcome effectiveness results in reducing risk factors or increasing protective factors for drug use or actual drug use initiation and use. Changes in knowledge and attitudes about drugs, without behavior changes, are not considered in this analysis as sufficient criteria for effectiveness.

The major goal of this paper is to identify and review the different types of prevention interventions being implemented with state or federal funding. According to the 1993 Government Accounting Office report "Drug Use Among Youth: No Simple Answers to Guide Prevention," a search to identify all federally supported approaches to substance abuse prevention produced a classification system containing nine different prevention approaches: information dissemination/media campaigns, outreach, education, health-related education and services, parenting/life skills training, social skills/resistance training, alternative activities, individual counseling, and family interventions/counseling. This search to identify current substance abuse prevention approaches produced basically similar types of interventions.

Recent trends have shown increased funding for research-based programs, particularly life and social skills as well as a small increase in parenting and family strengthening approaches. Comprehensive programming and alternative programs also have increased despite conclusive evidence concerning the effectiveness of alternative programs. In the past few years, interest in youth-led or youth involvement interventions, such as youth councils, youth advocacy groups, and youth community service programs, have increased with earmarked state funding beginning this year. Normative education approaches, although always a critical part of the earliest social influence programs developed by Evans and associates (1978), have now become more popular because research suggests they are more effective than peer resistance skills training (Hansen & Graham, 1991).

In this paper, the three major types of primary prevention are classified according to the Institute of Medicine (IOM, 1994) taxonomy of primary prevention. This more precise prevention system is based on the classification system proposed by Gordon (1987) and includes a continuum based on risk status of the participants, namely universal, selective, and indicated prevention programs. Research results of the major types of school, community, and family-focused programs for each of these three types of programs are discussed. Although some major prevention interventions are well known to prevention practitioners and researchers (e.g. highly marketed programs such as DARE, QUEST, and Here's Looking At You), other promising programs currently are being used in our nation's schools, community youth and family services agencies, and community partnerships. Many of these interventions warrant further research. The nature, advantages, disadvantages, content or methods, and research results are summarized briefly by universal, selective, and indicated programs. The primary focus is on describing research-based programs with published effectiveness research; however, "the Thousand Flowers," that are currently being tested in Phase IV or V demonstration/evaluation programs also are included to suggest directions for Phase III Controlled Intervention Trials (Jansen et al., 1996).

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Types of Prevention Interventions

A major issue in the prevention field is the degree to which programs should be targeted to specific at-risk groups or spread across all groups with no differentiation. A growing body of research (Thornberry, 1987; Thornberry, Lizotte, Krohn, Farnworth, & Jang, 1994) suggests that there are rather stable developmental trajectories for childhood conduct problems leading to drug use and delinquency in adolescence. This is encouraging some prevention providers to target the highest risk youth through selective or indicated prevention programs.

The research literature suggests that childhood antisocial behaviors or conduct disorders, anger, rebelliousness and anxiety, and shyness are predictive of later adolescent delinquency and substance use/abuse (Elliott, Huizinga, & Ageton, 1985a, 1985b; Kellam, Ensminger, & Simon, 1980; Windel, 1990). Early childhood aggression recently has become a major focus for prevention research, because it is a developmental marker for a variety of negative adolescent outcomes including delinquency and substance use (Hinshaw, Lahey, & Hart, 1993; Loeber, 1990). Aggressive children do not improve without some type of early intervention. If no prevention intervention is provided, their externalizing behaviors deteriorate as they grow older (Coie, Terry, Lenox, Lochman, & Hyman, 1995), leading to increased risk for substance use (Lochman & Wayland, 1994).

To help practitioners better match appropriate interventions to target populations, prevention experts redefined prevention approaches based on the groups for which they were designed (IOM, 1994). They concluded that there are three distinct types of prevention approaches:

1. Universal prevention strategies designed to prevent precursors of drug use or initiation of use in general populations, such as all students in a school



2. Selective prevention strategies designed to target groups or subsets of the general population, such as children of drug users or poor school achievers



3. Indicated prevention strategies created for participants who are already manifesting drug use initiation or precursors of drug abuse, such as conduct disorders, thrill seeking, aggression, and delinquency

Advantages, disadvantages, and examples of effective prevention programs for alcohol and drug abuse are discussed for each of these three categories of prevention.

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Universal Prevention Programs

Universal prevention programs include strategies designed to be delivered universally to general populations of youth and families. They can be provided by community groups or governments, churches, schools, and private nonprofit agencies. Media campaigns and public education are used to inform people about the programs. If delivered in schools, programs are provided for all students in the grades for which they are intended. These programs are generally shorter and less intensive than selective or indicated prevention strategies. Staff do not have to be as well trained because these approaches are often supported by video materials and highly structured curriculum materials. In schools, they can be led by the regular teachers or special external staff trained to deliver the program in the classroom.

A major advantage of universal prevention strategies is that they are frequently less expensive per participant because of shorter length, do not require special recruitment strategies or incentives for participation, and should include high-risk youth and families. Schools are the primary locus for drug abuse prevention efforts, because they allow universal access to all youth in schools. Hence, all students regardless of risk status can be accessed and served through universal school-based programs. Although some schools would rather "get back to basics" and not overburden teachers with additional tasks, most states mandate school drug prevention programs, health education, and teenage pregnancy and acquired immunodeficiency syndrome (AIDS) education. Many schools recognize that addressing behavioral and emotional risk factors (i.e., anger and lack of emotional control, conduct disorders, aggression, and lack of life and social skills) also helps to improve school achievement and success.

Unfortunately, at-risk youth and families frequently do not participate because of lack of attendance and involvement (e.g., school dropout, truancy, frequent absences, or illness) or beliefs that the content does not meet their individual needs. Universal school-based prevention programs must be targeted at the majority of students, so they frequently do not contain content tailored for ethnic students. The intensity, dosage, content, and method of delivery may be insufficient to change risk factors in higher risk students; hence, their effectiveness may be diminished, producing insufficient or temporary outcomes.

As shown in Table 1, a number of traditionally popular drug prevention approaches currently are being implemented in schools and communities. The major types are (a) cognitive and affective prevention approaches, (b) social influence approaches, (c) personal and social skills training, (d) youth-led approaches, (e) school climate change approaches, (f) community partnership approaches, and (g) parent involvement approaches. The earliest approaches implemented in schools and then tested in federal research were drug education and affective education approaches.

Table 1: Types of Universal School-Based Prevention Programs

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Cognitive and Affective Approaches

Information strategies include mediacampaigns, films, pamphlets, clearinghouse resource centers, radio-TV public service announcements, health fairs, advertisements, hot lines, and speaking engagements. This approach, which is a major method for providing information for adults, also is being implemented in schools and communities to target youth. Media campaigns provide needed information and affect the community's social norms when combined with other community prevention strategies (Wallack, 1986). In addition, the public demand for information about drugs is increasing and should be satisfied by accurate and scientifically credible messages. Since 1987, the Partnership for a Drug-Free America (1994) has produced more than 400 antidrug ads for their national campaigns worth $1.8 billion in media donations. According to Wartella and Middlestadt (1991), communication campaigns can be effective (a) when there is widespread acceptance of the campaign, (b) when media creates awareness and knowledge of the issues, (c) when information is used to recruit individuals, (d) when interpersonal communication channels such as peer networks are used to reinforce behavior changes (Rogers & Storey, 1987).

Media education is a prevention approach that seeks to educate youth about methods the media use to influence people. Media education was part of the social influence approach developed by Evans and colleagues (1978) at the University of Houston; it has been revised by many other researchers. The basis is McGuire's (1964, 1968) persuasive communication theory. Few studies have tested the efficacy of this approach only, rather than in combination with other strategies.

These programs seek to increase youths' awareness of drugs and of their health and social consequences. Many schools and colleges provide information on tobacco, alcohol, and other drug use as part of their health education classes or drug prevention programs. Drug education is based on the implicit assumption that adolescents behave in a logical manner and will not use drugs if they are given information. Botvin (1995) summarized, however, some of the ways drug education can be counterproductive and actually increase drug use in vulnerable students: (a) stressing the dangers of drug use may attract high-risk thrill seekers, (b) discussing pharmacological effects can arouse curiosity to try drugs firsthand, and (c) providing information on modes of administration tells students how to use drugs. Some studies (Swisher, Crawford, Goldstein, & Yura, 1971) show how information on drugs can increase experimentation. Providing new information to young children on commonly available household products used as inhalants can increase use, and presenting drug use as normative may suggest to some youth that they should use drugs to be normal and accepted. For some teenagers, any perceived short-term social benefit can override concerns with long-term consequences. Although research (Glasgow & McCaul, 1985; Goodstadt, 1980; Schaps, Bartolo, Moskowitz, Palley, & Churgin, 1981; Tobler, 1986) suggests that knowledge alone has not been effective in reducing drug use, it can be important to comprehensive programming and is crucial for lethal drugs or drug combinations. Additionally, education on drug consequences can serve as a basis for supporting peer norms that are unfavorable to drug use.

There is substantial evidence (Johnston et al., 1996) that information on the physical consequences of drug use is highly correlated with reduced use. Hence, providing accurate information, particularly about the most dangerous drugs, through credible sources or interesting group activities should be a part of universal programming. Unfortunately, there has been little research on ways to maximize the effectiveness of this approach. Prior programs that focused on physical consequences were rejected by researchers because it was thought the approach was ineffective when implemented alone (McCaul & Glasgow, 1985; Tobler, 1986). Also, these programs frequently relied on "scare tactics" by noncredible sources who provided inaccurate information, and the approach was rejected by youth. Some research (O'Neil, Glasgow, & McCaul, 1983) suggests that if these programs are creatively implemented with exciting interactive classroom activities, the results are positive, particularly in males.

Comprehensive school health programming,including substance abuse prevention, is rapidly being promoted. The American School Health Association (ASHA) and the Centers for Disease Control (CDC) are recommending that school health programs have one integrated curriculum for AIDS and prevention, substance use, teen pregnancy, violence prevention, gang prevention, and other health risks of youth. An example of an evaluated comprehensive school health curriculum is the NIDA-funded Healthy for Life Curriculum in Wisconsin (Piper et al., 1993). This program includes 56 sessions implemented in school classes over a 3-year period. Such an integrated approach is laudatory if it remains intensive and is imbedded within a total school commitment to reduce risk factors for substance use.

In the late 1960s, the drug culture flourished, affecting youth culture in music, dress, attitudes about traditional institutions, and drug use. It was hypothesized that youth heavily involved in use of marijuana, psychedelics, and sometimes heroin were lacking in self-esteem. As a logical consequence, affective approaches were developed that sought to improve self-esteem as a mediator of drug use (Kumpfer & Turner, 1990/1991). These approaches used ineffective methods such as "feel good" experiential games and classroom activities, rather than phased behavioral skills training. Affective programs have had no demonstrated impact on drug use itself (Kearney & Hines, 1980; Kim, 1988), but have had some impact on mediators such as school bonding and self-esteem (Battistich, Schaps, Watson, & Solomon, 1996). Despite their weaknesses, as verified in meta-analysis (Tobler, 1986), these approaches are still popular in schools and continue to be evaluated in NIDA research to determine their long-term effectiveness.

Although only a partial focus of the Napa Project, affective education programs aiming to increase youth self-concept or self-esteem were implemented and evaluated (Schaps, Moskowitz, Malvin, & Scheffer, 1986). Although there was no effect on 7^th grade males or 8^th grade males or females, this project produced a 1-year decrease in use of alcohol and marijuana, but not tobacco, in 7th grade girls (Schaps et al., 1986). These approaches, which did not appear to have negative effects, probably lacked sufficient dosage to single-handedly modify self-esteem or any actual precursors of drug use. Self-esteem has a distal, tangential, and complex relationship to drug use; hence, these prevention intervention studies may have been targeting the wrong risk factors. Studies have found high self-esteem in drug users, particularly when they begin use and before hitting the proverbial "rock bottom."

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Social Influence Approaches

This approach was the major school focus from the 1980s to the early 1990s. It has been extremely popular as a basis of many commercially marketed programs, because research suggests it is capable of reducing initiation to tobacco use and sometimes marijuana and alcohol use by 30-50%; however, booster sessions are needed or results decrease in 3 years (Pentz et al., 1989). Originally developed by Evans and his colleagues (1978) at the University of Houston, the approach has been revised by many other researchers. The bases are McGuire's (1964, 1968) persuasive communication theory and social and behavioral change theory.

The typical curriculum includes at least three major approaches: (a) social resistance skills training, from 3 to 12 sessions over 2 years in junior high taught by teachers or peer leaders (girls respond better to peer leaders), on how to resist peer offers; (b) psychological inoculation by an analysis of advertising appeals; and (c) normative education. Some studies also include a public commitment not to use drugs. The social resistance skills or refusal skills approach involves having students recognize high-risk situations in which they might use drugs and role play how to resist. The psychological inoculation approach developed by Evans consists of exposure to progressively stronger persuasive messages through films, media, and role plays. Students recognize advertising appeals and formulate counter arguments to those appeals.

This approach includes a 2-year, middle-school social influence curriculum based on earlier successes with Project SMART developed by this research team in Southern California (Pentz, 1995, 1997; Pentz, et al., 1989; Rohrbach, Graham, Hansen, Flag, & Johnson, 1987). The curriculum is implemented by trained teachers (Smith, McCormick, Steckler, & McLeroy, 1993). Although discussed in this section as an example of a social influence curriculum, Project STAR is more of a multicomponent program combining the classroom curriculum with comprehensive community interventions including mass media campaigns, parent involvement in homework, community coalition development, and health policy changes. A longitudinal follow-up study of participants when they were seniors in high school showed 30% less marijuana use, 25% less cigarette use, and 20% less alcohol use compared to controls.

These are based on interventions developed by Evans and associates (1978) to correct students' overestimations of the prevalence of drug use. Prior research (Fishbein, 1977) suggested that adolescents tend to believe that more youth are using tobacco, alcohol, and other drugs than actually are. Providing periodic classroom surveys of tobacco use and publishing the results corrected misjudgments that almost all students were smoking and reduced smoking rates by half over the control rate. Perkins and Berkowitz (1992) tested the normative education approach with college students and found it to be effective in reducing drug use rates.

AAPT is an elementary school classroom program for 5th graders with booster sessions in the 7th grade (Donaldson, Graham, & Hansen, 1994). It offers normative education and resistance skills training, which in combination were more effective than resistance skills only. Hansen and Graham (1991) tested the relative contribution of the normative education component versus the peer resistance component in AAPT. The normative education program was more effective and significantly reduced alcohol consumption, marijuana use, and cigarette smoking. The results suggested that previously reported positive effects of peer resistance skills training programs may have been caused primarily by the normative education components in the programs. Ellickson and Bell (1990) similarly concluded that the lack of effectiveness on alcohol reduction after 1 year of their social influence resistance training program, ALERT Drug Prevention, may have been because more positive peer norms existed for alcohol than for tobacco or marijuana. AAPT served as the basis for the improved All Stars Program (Hansen, 1996), which focuses even more on normative education.

This program was created by Hansen (1996), who first worked with Evans (1978). The 13-session classroom curriculum focuses on normative education. Trained teachers use highly interactive classroom activities, role plays, games, debates, art projects, videotaped performances, and active discussion. A symbolic ring and certificates are awarded at graduation. The program targets three of four variables that Hansen's meta-analysis research (Hansen, Rose, & Dryfoos, 1993; Hansen & Rose, in press; Hansen, under review) suggests mediate drug use: (a) personal commitments to avoid drugs; (b) life goals, values, and ideals incongruent with the high-risk behaviors; and (c) conventional beliefs about social norms regarding high-risk behaviors. The fourth mediator, bonding with prosocial institutions, is only indirectly addressed; that is, youth enjoy school more and possibly bond with the teacher or students in the class.

Pilot study results suggest the program was implemented with fidelity. Compared to students who received DARE in the 7th grade, the All Stars students (N = 102) had significantly better outcomes on all four mediators and rated the program more highly. Given the relatively small number of subjects compared to the significance levels (p <.0001 to .0002 and F-values of 34.74 to 14.31), the effect sizes are quite large for a school-based program. There were gender x condition main effects for commitment and ideals, but not for expressed bondedness and normative beliefs. One reason for the very large statistical differences between the two compared programs is that the DARE students significantly decreased on these four variables between the pre- and posttest, whereas the All Stars students significantly increased. The worsening of "key mediators for drug use as students mature is normal and is the primary reason for increases in drug use over time" (Hansen, 1996, p. 1368). Without a no-treatment control group, it is difficult to tell whether the DARE program helped to reduce this decrease in positive mediators or whether these students were totally unaffected by the DARE program and were similar to a no-treatment control.

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Personal and Social Skills Training

These approaches are becoming more popular because of the long-term effectiveness of Botvin's Life Skills Training Program. The bases are Bandura's social learning theory (Bandura, 1986) and Jessor's problem behavior theory (Jessor & Jessor, 1977). Other underlying assumptions are that drug use is functional; that it is socially learned through modeling, imitation, and reinforcement; and that it is influenced by an adolescent's cognition, attitudes, and beliefs. The curricula include teaching of generic personal self-management skills and social skills by teachers, health educators, college students, and same-age or older peer leaders. Programs last for 7 to 20 sessions with 10 to 15 sessions as the average and are taught in health or drug education classes or in science, social studies, or physical education classes.

The immediate results of these programs are very positive, with 40-80% reductions in drug use. However, most studies found erosion of results within 3 years or by the end of high school (Ellickson & Bell, 1990).

The LST program (Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995; Botvin, Baker, Filazzola, & Botvin, 1990; Botvin, Schinka, Epstein, & Diaz, 1995) is one of the programs highlighted in the NIDA (1997) monograph. It is a 3-year, middle school personal and social skills program including 30 sessions of drug resistance skills, normative education, and self-management, communication, and other life skills. A 6-year follow-up study with 6,000 students in 56 schools found that weekly use of polydrugs (tobacco, alcohol, and an illegal drug) was 66% lower than control schools. Any use of tobacco, alcohol, or marijuana was 44% lower than control schools. Program fidelity was better in teachers who attended annual training workshops and received ongoing support.

Because LST and other programs are conducted in schools, the programs have not been modified to be culturally appropriate, except for some changes in reading level, language, role play scenarios, and examples appropriate for the target population. In a New York State study with 74% Hispanic students and 11% African American students, Botvin found positive effects in knowledge of consequences, smoking prevalence, social acceptability of smoking, decision making, normative expectations of adult smoking, and peer smoking. Similar results were found in two New Jersey studies with 78% to 87% African American students (Botvin, Batson, et al., 1989; Botvin & Cardwell, 1992).

Social problem-solving skills training has been combined with education on the relationship between drugs and violence. A 15-session program was implemented daily (50 minutes) in 5^th grades for 3 weeks by experienced trainers (including an attorney, a trauma nurse, and a paraplegic former drug dealer). An evaluation (Gainer, Webster, & Champion, 1993) found positive effects on youth responses to hypothesized social conflict situations and beliefs about aggression and violence.

Although social skills training approaches employ a wide variety of intervention methods, most of them use behavioral skills training techniques involving demonstrations of effective and ineffective behaviors, trainer demonstrations, participant role plays with feedback, and reinforcement for behavior changes. These programs often address a wide variety of general social skills or competencies, such as assertiveness to avoid negative influences (offers to use drugs), communication skills, decision making, ability to restore self-esteem, anger and stress management, and social skills to make prosocial friends.

The IOM (1994) review of substance abuse prevention concluded that when combined, peer resistance and normative approaches have some effectiveness in "producing modest significant reductions during early adolescence in the onset and prevalence of cigarette smoking, alcohol, and marijuana use across a number of experimental studies conducted by a variety of investigators" (Ellickson & Bell, 1990; Hansen, 1992; Hansen, Johnson, Flay, Graham, & Sobel, 1988; McAlister, Perry, Killen, Slinkard, & Maccoby, 1980). Peer-led classes appear to be more effective than teacher-led classes (Botvin et al., 1990; Goplerud, 1990; McAlister, 1983; Perry, Klepp, Halper, Hawkins, & Murray, 1986; Perry et al., 1989). Bruce and Emshoff (1992) hypothesized that "peers may provide a more credible message in helping to form antidrug norms or may help to create a more realistic context for the acquisition and practice of peer refusal skills" (p. 11).

School-based universal programs are not without potential risk for high-risk or drug-using students. Several studies have found increased use of tobacco and alcohol in students who were already using these substances (Ellickson & Bell, 1990; Gottfredson, 1990; Moskowitz, 1989). The IOM (1994) concluded that school campaigns that show drug use as nonnormative behavior may further isolate students who are already using drugs. Special selective prevention approaches are needed to avoid isolating high-risk students from positive, nonusing friends.

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Youth-Led or Youth Involvement Approaches

The youth-led or youth involvement approach seeks to promote protective mediators for drug use, such as self-empowerment, leadership, planning, decision making, opportunities for success, team-building skills, and commitments to remain drug free through school and community advocacy. The interactive, skill-building approach employed in youth-led programs has been supported by the meta-analysis of Tobler and Stratton (1997). However, the leadership training and empowerment aspects have been less researched. Most of these activities are currently being implemented as universal prevention programs in schools and communities; however, such implementors are making major efforts to involve high-risk youth. The underlying assumption appears to be that at-risk youth will respond more favorably to substance abuse prevention programs if other young people from the same community play substantial and meaningful roles in the management and operation of such programs. The primary hypothesis is that youth-led approaches to prevention will be more successful than adult-led activities in reducing substance abuse and other problem behaviors.

Published research supports this hypothesis. A few school-based social influence researchers (Botvin et al., 1990; McAlister, 1983; Perry et al., 1986; Perry et al., 1989) have found that peer-led classes appear to be more effective than teacher-led classes. However, the operationalization of this concept in practice in communities today is much broader than simply training youth to implement a researcher-designed and researcher-controlled curriculum. It is difficult to define youth-led strategies, and much confusion exists. The critical elements or principles of successful youth-led prevention activities have not yet been defined, because researchers have not tested these approaches in Phase III Controlled Intervention Trials. Many of these youth-led approaches have grown out of grassroots ideas within comprehensive community partnership grants funded by CSAP, CDC, and the National Institute of Justice (NIJ). Hence, they have not been tested as independent components.

The major approaches currently being funded are (a) youth councils and youth governments; (b) the President's Crime Prevention Council Projects, including the Office of Juvenile Justice and Delinquency Prevention (OJJDP) 1996 and 1997 Ounce of Prevention grants; and (c) CDC's Kids Coalition and Smoking Prevention youth minigrants.

Youth councils for crime and substance abuse prevention exist in many of our cities and states as Governor's Youth Councils and Mayor's Youth Councils. Generally, they are staffed by prevention or youth specialists who solicit nominations of youth from their area to serve for a year on a youth council. Youth councils vary in their attempts to recruit high-risk youth as well as high-status peer leaders. Dishion and Andrews'(1995) research on the iatrogenic effects of clustering problem youth suggests that having a mix of youth would produce better effects, but this is an empirical question worth testing in the area of youth-led activities. Sometimes prosocial, high-status voluntary college interns are used as assistants and positive role models. Activities include participating in community service projects, such as neighborhood cleanups, and advising the governor or mayor on youth issues, recreation, and sports.

Although not new, a more intensive skill-building approach is implementation of youth governments. This approach involves having high-risk youth, who show promise, serve as youth officials for each major part of state, county, or city government. Hence, students would serve as the youth city mayor, the city treasurer, the commissioner of social services or health, and so on. These youth spend time with their mentor, the government official serving in the same public office, after school and on weekends, shadowing their activities and learning professional competencies and aspirations. In addition, the youth government meets and makes recommendations on public services or laws from the perspective of community youth. If implemented as intended, youth governments could provide substantial skills training and increase commitments to traditional values. This promising approach has not been evaluated in the published research literature.

These constitute a systematic attempt to involve youth more in prevention activities (e.g. OJJDP's 1996 and 1997 Ounce of Prevention grantee projects). A review of these funded projects reveals that these grantees are working primarily within community coalition or partnership models. Although the grantees were asked to focus on youth-led organizations, the funded projects were still adult-led and adult-supported, probably because youth-led organizations are rare. Most of the coalitions or collaboratives are examining existing youth and family services and creating plans to improve those services - hopefully with youth input. Because of the broad definition of youth-led activities, these coalitions are implementing many different types of approaches, including mapping and publishing projects of youth services and resources in the community, needs assessments of youth needs or gap analyses of services compared to needs, peer leadership and mediation projects, cross-age tutoring and mentoring, youth-staffed support lines, and other youth activities within coalitions, including serving as youth representatives on coalition advisory boards or councils. For a summary of youth activities for the nine fiscal year 1996 Ounce of Prevention grantees, see Table 2.

Table 2: Ounce of Prevention youth-led activities

Another approach to youth-led activities has been spearheaded by the CDC through their funding to state health departments for IMPACT (Initiatives to Mobilize for the Prevention and Control of Tobacco Use). One spin-off of these grants has been the development of Kids Coalitions to lobby for passage of clean air acts and for a tax increase on tobacco. In addition, this year CDC funded states to implement youth minigrants ($500). Through IMPACT KIDS (Kids Involved in Discouraging Smoking) minigrants in schools, one adult supervisor works with a group of at least five students to implement specified community environmental change prevention approaches. Funded activities have included (a) measuring the amount of tobacco advertising and placement of tobacco products in stores; (b) developing an antitobacco Web site and a talk line or referral service; (c) conducting compliance checks for "tobacco stings" with law enforcement, conducting retail education on laws concerning youth access to tobacco, and publishing surveys of tobacco accessibility at businesses; (d) developing peer education or student-led programs to teach other students about tobacco prevention and reduction; (e) encouraging tobacco legislative advocacy including writing and seeking legislators or council members to introduce and support youth-written legislation; (f) developing antitobacco messages that target teenagers and displaying them in schools and businesses; (g) enhancing efforts to reduce tobacco promotion and advertising, and supporting the implementation of teen tobacco reduction and cessation programs.

Evaluations of CDC-funded youth-led activities have been limited and consist primarily of process evaluations demonstrating that the proposed activities were implemented. Outcome evaluations on the hypothesized changes in the youth involved--such as increased commitment to remain tobacco free, increased involvement with non-tobacco-using peers, increased school bonding, increased self-efficacy, and leadership competencies--have not been tested, despite the promising nature of these youth-involvement activities.

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School Climate Change Approaches

This type of prevention program seeks to change the total school environment to be more supportive of nonuse, but also to address many of the mediators for drug use, such as school bonding, self-esteem, association with nonusing friends, a supportive school climate, and positive family relations (Kumpfer & Turner, 1990/1991). School climate change approaches resemble community change coalition approaches but are conducted with an emphasis on the school or school district. Task forces are mobilized to plan, implement, and evaluate locally developed solutions to empirically identified problems derived from a baseline needs assessment. Many different solutions are implemented, including universal interventions for the total school (e.g., school pride days, assemblies, theater performances, school policy changes, curriculum changes, and school structure changes, including cooperative learning), selective interventions for high-risk students (e.g., children of alcoholics groups, theater troupes for high-risk youth, peer leadership classes, new student welcome programs, buddy programs for freshmen, and mentoring programs), and indicated interventions (e.g., peer counseling, teen hotlines for in-crisis youth, and support groups for recovering students).

This was one of the first comprehensive school climate change programs to be tested and to demonstrate positive results (Gottfredson, 1986). The program involves students, parents, teachers, school officials, and communities in planning teams that follow a specific planning process called the Program Development Evaluation (PDE) method, including a needs assessment, development and implementation of plans to address the substance abuse risk factors, and explicit standards for performance with constant feedback (Gottfredson, 1984; Gottfredson & Gottfredson, 1989). Hence, the school/community partnership teams are free to develop many different strategies and evaluate their effectiveness, making this project the precursor for the popular community partnership approaches. Implemented in junior high schools in Charlotte, South Carolina, this program affected many mediators and actual tobacco, alcohol, and drug use in the participating schools compared to nonparticipating schools.

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Coordinated Community Partnership Approaches

In the 1990s, primary prevention specialists and funding sources are stressing a universal community partnership approach involving massive community organizing to create infrastructures to support prevention work. This area, although important as an effective prevention approach, already has been reviewed by the author (see Kumpfer, Whiteside, & Wandersman, NIDA 1997), so less about community partnerships will be included in this overview of prevention.

Community partnership approaches to prevention have become popular in recent years for several reasons:

• Coordinated efforts with non-conflicting messages are thought to be more effective than single-shot programs.



• Drug use or abuse is multicausal and comprehensive; coordinated efforts should address more risk and protective factors.



• Involving many different community organizations, including the media, as shapers of community values, attitudes, and norms, can have an impact on improving a community's norms about alcohol abuse and drug use.



• Local solutions are more effective and more likely to continue operating after the initial funding than programs designed, dictated, or operated by those outside the community.



• Community leaders across the nation believe that wide-scale community involvement of all segments of their communities is required to reduce the drug problem successfully.

This approach seeks to locate Aislands of health@ in high-risk neighborhoods and communities and to mobilize their combined strength to design locally tailored interventions or environmental change programs to reduce drug use. Community partnerships can mobilize substantial fiscal and voluntary support by recruiting and empowering the civic societies in a community to join them in their Awar on drugs.@ Although schools, law enforcement agencies, alcohol and drug prevention providers, parents, and youth are frequent participants in substance abuse prevention efforts, according to a Join Together study (1993), a number of critically important community organizations have not been very involved, namely labor, business, the media, religious organizations, universities, and transportation. Since this Join Together study was completed, more religious institutions, universities, and the mass media have become involved in partnership activities. Congress recently approved $198 million in matching funds for a special partnership between the White House Office of Drug Control Policy and the Partnership for a Drug-Free America to produce a national drug-free media campaign targeting youth 8-14 years old.

One of the earliest community partnership approaches for substance abuse prevention was the Midwestern Prevention Project (i.e., Project STAR) highlighted in the NIDA (1997) monograph of effective prevention programs. This prevention partnership brought together a number of community leaders in partnership with community foundations (the Kaufman Foundation and the Lilly Foundation). A number of community activities were provided, including a school-based drug prevention curriculum, parent involvement activities, community canvassing and volunteer training, a media campaign involving youth, and health policy changes. The evaluation results were quite positive (Pentz et al., 1989, 1990) and encouraged other foundations and Congress to fund community partnership programs.

Beginning with the Anti-Drug Abuse Act of 1988, Congress tasked CSAP to fund over 250 community partnerships for drug abuse prevention (Davis, 1991). Additional substance abuse prevention community partnerships have been implemented nationwide by the following groups:

• National foundations, such as the Robert Wood Johnson Foundation's Fighting Back and Join Together coalitions, the Annie Casey Family Foundation (which is working with CSAP on the Starting Early/Starting Smart initiative), and the Henry J. Kaiser Family Foundation



• Federal Public Health Service agencies and their special initiatives, such as the National Cancer Institute's COMMIT and ASSIST tobacco and cancer reduction programs (Pierce, Giovino, Hatziandreu, & Shopland, 1989), and the CDC's Planned Approach to Community Health (PATCH) health promotion program (Kreuter, 1992) and the Bureau of Justice Assistance's Weed and Seed and Comprehensive Communities programs



• State and local governments, such as the model programs in Rhode Island and the Communities That Care model (Hawkins, Catalano, & Miller, 1992) implemented originally in Oregon and later in a number of states and local communities through National Performance Review Laboratory or Weed and Seed partnerships

Despite this massive infusion of demand reduction funding into the area of community partnerships, there is still little research demonstrating the effectiveness of these approaches. Although logically appealing, there are few randomized control trials to demonstrate clearly the effectiveness of community partnerships. One of the problems is that it is almost impossible to conduct true randomized control trials with communities. To help with the difficulty in evaluating large communities, geo-mapping methods are now being used to match smaller communities and to evaluate the differential impact of prevention efforts in some communities.

Although a coordinated community approach is more likely to be effective than single-shot school curricula, this massive infusion of funding and effort ignores critical improvements in prevention programming in the Cinderellas of Prevention - family and environmentally based prevention approaches (Kumpfer, 1989).

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Family-Focused Universal Prevention Approaches

More risk and protective factors can be addressed when family members are involved in drug prevention approaches. A number of youth social skills training approaches, therefore, have been combined with parent training or family skills training. Examples of school-based, universal family-focused strategies effective in reducing tobacco, alcohol, or drug use include Hawkins and Catalano's Preparing for the Drug-Free Years (Spoth, in press), Parent Drug Education Homework Involvement (Pentz et al., 1989), Iowa Strengthening Families Program (Kumpfer, Molgaard, & Spoth, 1996), and Adolescent Transitions Program (Dishion, Andrews, Kavanagh, & Soberman, 1996; Dishion, Kavanagh, & Kiesner, in press). Each of these is described in more detail in the NIDA publication, Preventing Drug Use Among Children and Adolescents: A Research-Based Guide (NIDA, 1997).

To increase the effect size of universal school or community programs, many well-known school-based researchers (e.g., Biglan, Botvin, Dielman/Cherry, Flay, Hawkins, Kumpfer/Spoth, Pentz, and Schinke) currently are testing the efficacy of an added parenting or family component. Family and school-focused programs showcased in the recent NIDA (1997) publication are the Project Family in Iowa, the Seattle Social Development Project (Hawkins et al., 1992), and the Adolescent Transitions Program (Dishion et al., in press) discussed in more detail below.

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Effectiveness of Universal Approaches

School-based substance abuse prevention approaches have been reviewed several times (Bangert-Drowns, 1988; Bruvold & Rundall, 1988; Hansen, 1992, 1993; Moskowitz, 1989; Tobler, 1986; Tobler & Stratton, 1997). The most recent published review of effectiveness of 41 school-based substance abuse prevention approaches (Hansen, 1992), including research results from 1980 to 1990, revealed a wide variety of different theoretical bases and intervention approaches. Hansen (1992) classified them into 12 different approaches, including information, decision making, pledges, values clarification, goal setting, stress management, self-esteem building, resistance skills training, life skills training, norm setting, student assistance (peer counseling, peer leadership, professional counseling, hotlines), and alternatives. Social influence programs including resistance skills training, norm setting, and life skills had the largest percentage of positive findings: 51% positive, 38% neutral, and 11% negative. When corrections were made for programs with insufficient power (not enough schools or groups) to detect a significant change, 63% of the programs had positive results, 26% neutral, and 11% negative. After power was corrected, comprehensive school programs were more effective, with 72% positive, 28% neutral, and no negative effects reported. Among the comprehensive programs, two program models B Life Skills Training (Botvin et al., 1990) and STAR (Pentz et al. 1990) B and two other similar programs (SMART and AAPT) contribute to successful outcomes. The information/values clarification programs had mixed results: 30% positive, 40% neutral, and 30% negative outcomes. Affective education also had positive effects (42%) balanced by 25% negative effects and 33% no effect. There were not enough studies with reported results to determine overall effectiveness of the alternatives approach.

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It appears that the most effective universal prevention programs implemented in schools are those that involve more intensive social or life skills training and often include homework assignments with parents. NIDA has been instrumental in funding research for the development and evaluation of many of these programs. Preventing Drug Use Among Children and Adolescents: A Research-Based Guide (NIDA, 1997) includes program descriptions of some of these exemplary school-based prevention programs. The programs listed below are universal research-based programs with positive results in reducing tobacco, alcohol, or drug initiation. Program descriptions appear in the NIDA (1997) "red book" publication:

• Adolescent Alcohol Prevention Trial (AAPT) (Donaldson et al., 1994) is an elementary school classroom program for 5th graders with booster sessions in the 7th grade. It offers normative education and resistance skills training.
• Life Skills Training (LST) Program (Botvin et al., 1990; Botvin, Baker, et al., 1995; Botvin, Schinke, et al., 1995) is a 30-session, 3-year, middle school personal and social skills program.
• Project STAR (Pentz, 1995, 1997; Pentz et al., 1989) is a 2-year, middle school social influence curriculum, implemented by trained teachers, combined with comprehensive community interventions.
• Seattle Social Development Project (Hawkins, Catalano, & Miller, 1992) is a comprehensive teacher training, social skills training, and parent training program<./li>

Additional examples of effective universal programs funded by other federal agencies (National Institute on Alcohol Abuse and Alcoholism [NIAAA], CSAP, National Cancer Institute [NCI]) include the following:

• Project Northland (Perry et al., 1993; Perry et al., 1996) is a comprehensive program with developmentally appropriate activities for classrooms from elementary school to junior high school. One unique feature is a cartoon series with major characters each year and parent involvement in homework assignments.
• Alcohol Misuse Prevention Project is an alcohol prevention program (Dielman, Shope, Leech, & Butchart, 1989). This middle school classroom program reduced alcohol use significantly, but only in the highest risk youth whose parents allowed them to drink at home (Shope, Kloska, Dielman, & Maharg, 1994). Additionally, these differential results did not show up until the 8th and 9th grades in the annual follow-up study when the control group began escalation of their alcohol use. This "sleeper effect" demonstrates the need for follow-up assessments until the age when youth would normally demonstrate increasing levels of substance use for the population.
• Woodrock Youth Development Project (LoScuito, Freeman, Harrington, Altman, & Lamphear, 1997) is a comprehensive community and school program that includes human relations and skill-building workshops, drug resistance training, and psychosocial family and community supports.
• Say Yes, First (Zavala, 1996) includes training of school staff, comprehensive health education, academic improvement and enhancement programs, parent education and involvement, and drug-free alternative activities.

All of these prevention programs include teaching social competencies or peer-resistance skills. Some effective programs focus more on broader life skills (Botvin's LST) and some on normative changes (Hansen's All Stars). These theory-based social competency programs differ in a number of ways from other similar school-based programs found to have minimal effects (Tobler, 1986; Tobler & Stratton, 1997), such as DARE (Ennett, 1994; Hansen & McNeal, 1997). They have stronger curricula targeting a larger number of primary risk factors for drug use, improved fidelity to their curricula in implementation, increased dosage or intensity, better training of implementers, more skills-based curricula, and interactive teaching methods.

Tobler and Stratton (1997) conducted a recent meta-analysis of the effectiveness of school-based drug prevention programs. A meta-analysis involves collecting data on all the researched programs, categorizing types, and then comparing effectiveness of different major types of programs by averaging the size of the effects. Some programs have a small effect, some have a moderate effect, and some have a large effect on the precursors of drug use. This statistical analysis revealed that only programs using interactive, skills-training methods as opposed to didactic lecture methods were effective in reducing drug use risk factors and actual alcohol, tobacco, and other drug use. In other words, these universal programs sought to change behaviors by teaching skills and competencies rather than just changing knowledge and attitudes by providing lectures on the consequences of tobacco, alcohol, or drug use.

Donaldson and associates (1996) have conducted an analysis of social influence-based drug abuse prevention programs B the basis for most of the well-researched and successful prevention strategies. They conclude that Athis type of programming has produced the most consistently successful preventive effects@ (p. 868) with the general population, but may not be as effective with high-risk youth. Unfortunately, most of these programs rely on a mixture of several prevention approaches, so it is difficult to determine the most salient content. Donaldson and associates conclude that the most essential ingredient for success appears to be changing social norms or peer norms rather than training students in refusal skills. They warn against schools or communities implementing only a subset of the lessons of exemplary programs because of the potential of choosing only the less effective lessons.

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Parent Involvement Approaches

Parent involvement approaches seek to get parents to learn about substance abuse prevention strategies by having them do homework assignments with their children. School-based prevention programs have had difficulties in attracting parents when they want to involve all parents in a universal intervention. Even when stipends for participation were offered, researchers (Grady, Gersick, & Boratynski, 1985) recruited only about one-third of the eligible parents. If parents are only requested to complete homework assignments at home with their children, parent involvement is higher. Flay and associates (1987) found 94% of students reported that their parents participated in the homework assignments and, more important, that parent involvement may have influenced program success. Perry and associates (1986, 1989) found that 70% of parents reported their adolescents had brought home a parent/adolescent smoking prevention program homework assignment. The results of Project Northland, which focuses on parent involvement in the 6th grade, show that 94-98% of the intervention students in 10 school districts reported that they had participated in the parent/child homework assignments (Perry et al., 1993). However, there were no significant effects on smoking or drinking by the end of the 6th grade, possibly because the base rates were very low.

Results from the Midwestern Prevention Program found that about 66% of parents (completing a parent survey about parent involvement) are willing to participate in I-STAR curriculum homework assignments with their children, 23% attended a two-session family skills training program and prevention meetings, 9% served on the parent committee, and 7% participated on the I-STAR Community Advisory Council (Rohrbach et al., in press). The independent contribution of the parent involvement strategy has not been tested in randomized clinical trials and is recommended for further research.

Project Family (Spoth, in press) is a research project that includes evaluating two universal, research-based, family-focused programs: (a) Preparing for the Drug-Free Years (PDFY), a five-session parenting program developed by Hawkins and Catalano (1994) and (b) the Iowa Strengthening Families Program (ISFP), a seven-session family skills training program developed by Molgaard and Kumpfer (1994), which is a modification for 6th graders of the Strengthening Families Program for 6- to 10-year-olds (Kumpfer, DeMarsh, & Child, 1989). Additionally, this project conducts market research on factors related to family participation and retention as well as a statewide needs assessment for family and community needs.

Results (Spoth, Redmond, & Shin, in press) show positive effects of medium effect sizes of both family programs on child management practices and parent-child affective quality. A 2-year follow-up on ISFP found significant intervention-control differences in positive parent-child affective quality (Spoth, 1997). A 1-year follow-up on ISFP showed improvements in critical mediators of substance use, namely increased peer resistance, reduced bonding to antisocial peers, and fewer problem behaviors. Using growth curve analysis, the 2-year follow-up data show significant differences between the ISFP and control group in problem behaviors, gateway substance use, minor delinquency, school-related problem behaviors, and affiliation with antisocial peers. Latent transition analysis of dichotomous substance outcomes indicated positive intervention-control differences in probabilities of transitioning to more advanced stages of use. The market research (Spoth & Redmond, 1995; Spoth, Redmond, Haggerty, & Ward, 1995) suggests that parents say they would like flexible scheduling, minimal initial time commitments, contacts with parents' peers, and multiple incentives, such as food, refreshments, and child care.

Seattle Social Development Project (Hawkins et al., 1992) is a universal, comprehensive elementary school program combining teacher training in active classroom management, interactive teaching strategies, and cooperative learning with three developmentally appropriate parent training curricula: AHow to Help Your Child Succeed in School,@ ACatch >Em Being Good,@ and APreparing for the Drug-Free Years.@ Longitudinal studies found reductions in drug use incidents in school and improvements in other drug use precursors (antisocial behavior, lack of academic skills, alienation and lack of school bonding, and bonding to antisocial others).

Adolescent Transition Program (ATP) (Dishion et al., in press) is a middle school multicomponent program that integrates universal, selective, and indicated approaches to meet the needs of all students and parents. A Family Resource Room is established to disseminate information about risks for substance abuse and effective family management skills through print and video materials. At the selective level, the Family Check-Up provides a family assessment and professional support to help families determine their level of risk. At the indicated level, the Parent Focus curriculum provides direct support through behavioral family therapy, parenting groups, or case management services. Results of a series of intervention trials indicate that the parent interventions are effective in reducing the escalation of drug use in high-risk youth. Also, by testing a youth-only group, with and without the parenting group, and a parenting group only, these researchers discovered that problem behaviors can worsen in child-only groups compared to the parenting-only groups.

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General Practice in Universal Prevention Programs

The most popular education programs (DARE, QUEST, Here's Looking At You) are based on combinations of education, affective, social influence, and social skills training approaches. Although they contain some components, such as the social influence content, that have been found to be effective in reducing drug use in adolescents, according to Botvin (1995), their curricula are often poorly implemented and taught by individuals with little or no training or expertise. Hansen (1992) found that even when research-based programs are adopted by schools, they are frequently shortened, which omits crucial elements, and teachers stray from the content by adding their own ideas and material.

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DARE, currently the most popular school-based prevention program, is provided to over 6 million students at a cost of over $750 million (Koch, 1994). Most of these students are 5th graders in elementary school; however, DARE has revised its curriculum nine times and now includes 7th and 10th grade boosters. In a recent survey study commissioned by DARE, 97% of the students completing the program made spontaneous positive comments about it. Its popularity with students can be explained partially by the fact that the program gives youth many gifts (e.g., tee shirts, bumper stickers) at graduation, and the police officers drive Ahot@ DARE cars. Teachers like it because the police officers deliver the program, thus giving the teachers a break in class. Also, it is aggressively marketed, and funding is amply available from local police departments or schools through federal sources such as NIJ and the Department of Education's (DOE) Drug-Free Schools grants.

The curriculum content originally was based on prototype versions of two Project SMART programs (Hansen et al., 1988) and included resistance skills training, self-esteem building, stress management, public commitment, and drug education on consequences. New content includes information on gangs and legal issues and involves 7th and 10th grade booster sessions.

DARE is constantly being revised to include more methods suggested to be effective by other research studies; hence, it is difficult to determine the effectiveness of the current program. Glenn Levant, the founding director of the Los Angeles-based organization, reported at the DARE annual conference attended by 2,300 police officers and educators in Salt Lake City in July 1997 that DARE is now in about 25% of schools nationwide with an annual budget of $210 million. DARE officials recommend that schools adopt the newer 17-week course that is presented in the 5th, 7th, and 10th grades.

DARE officials argue that the recent unfavorable research studies are sales tools for competing antidrug programs. However, a number of the DARE program evaluators are not competitors; they are well-respected researchers in the field. The research conducted on prior versions suggests that DARE has a small but consistently positive impact on student self-reports of reductions in tobacco use (Clayton, Cattarello, & Johnstone, in press; Ennett, Rosenbaum, et al., 1994; Ennett, Tobler, et al., 1994), but not other drugs.

Using hierarchical linear modeling (HLM) to examine how DARE affects 12 hypothesized mediating variables, Hansen and McNeal (Hansen & McNeal, 1997; McNeal & Hansen, 1992) concluded that DARE does not appear to address or affect mediators that offer strong potential paths for intervention effectiveness. Although several mediators were affected mildly by program exposure (e.g., manifest commitment not to use tobacco or alcohol, normative beliefs concerning drug dealing, social skills, and stress management), only manifest commitment was significantly associated with reduced drug use. Conversely, the increase in social skills had a nonsignificant negative impact on drug use. All other mediating variables had no effect (e.g., normative beliefs, lifestyle incongruence, consequence belief, decision skills, resistance skills, self-esteem, stress management, perceived alternatives, goal setting, and assistance skills).

DARE appears to work primarily by enhancing youth's commitment not to use tobacco, alcohol, or other drugs. Unfortunately, as youth move to higher grades, the social and internal pressures to use these substances tend to swamp the early commitment not to use them. Hansen and McNeal (1997) recommend that" the D.A.R.E. program . . . be replaced by a curriculum that has the potential to target and alter variables that truly mediate substance use and other problem behaviors" (p. 175), such as normative education.

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Summary and Research and Practice Recommendations

In general, reviews of the literature or meta-analyses (Hansen, 1992; Moskowitz, 1989; Tobler, 1986) show that Athe hoped-for magnitude of effects of school programs are rarely achieved@ (Hansen & McNeal, 1997, p. 166). Promising approaches have been identified in reviews of the research (Hansen et al., 1993), but consistently positive effects across different sites appear only for the social influence and life skills approaches (Kumpfer, 1997a, 1997b).

The appropriate response in prevention science now is to examine the reasons for such failures and to design stronger programs. The new Tobler and Stratton (1997) meta-analysis suggests that interactive methods are crucial to effective prevention programming. The social influence or social and life skills curricula involve students more in experiential exercises. Whether involvement, self-discovery, and skill building are critical ingredients in successful universal programs should be tested further in empirical research. Rather than using Ablack box@ evaluation designs of multicomponent programs, research is needed that will allow researchers to dismantle independent variables and determine the relative contribution of the different approaches. Many universal prevention programs are so complex that it is difficult to determine the salient independent variables.

Local etiological research or needs assessments are needed to assure that the selected prevention program is addressing the most salient risk or protective factor mediators in local youth. Hawkins and Catalano (1994) use a similar approach with their Communities That Care community risk factor analysis, except that in addition to existing social indicators, direct baseline assessment of students should be used to determine criteria for matching program content to appropriate mediating processes. This approach was used for Projects PATHE and HI PATHE (Kumpfer, Turner, & Alvarado, 1991); structural equations modeling was used to verify the locally relevant pathways to drug use for males versus females and different ethnic groups (Kumpfer & Turner, 1990/1991).

Schools implementing research-based prevention approaches should seek to implement them with as much fidelity to the original curriculum and process as possible. Efforts should be made to provide sufficient training and to observe facilitators randomly to assure fidelity.

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