James Colliver
The purpose of this work group is to discuss the implementation and application of school-based prevention programs, identify issues, develop recommendations regarding prevention research and practice, and make recommendations for new materials and services.
The panel leading the discussion includes Dr. Gilbert Botvin, a prevention research scientist, Ms. Jodi Haupt, a State representative of the National Prevention Network, and Mr. Cecil Short, a community leader. Dr. Botvin is the director of the Institute for Prevention Research at Cornell University's Medical Center in New York City. He has many years of experience as a prevention researcher and he is the developer of the Life Skills Training program, a school-based approach to drug use prevention. Our community leader, Cecil Short, is president-elect of the National Association of Secondary School Principals and a middle school principal in Riverdale, MD. Jodi Haupt, our National Prevention Network representative, is a program coordinator at the Missouri Division of Alcohol and Drug Abuse. Ms. Haupt and Mr. Short each will
have 5 minutes to respond to Dr. Botvin's speech from this morning; Dr. Botvin will then take 5 minutes to comment on the issues raised by the other panelists and clarify any points from his presentation.
Jodi Haupt
I appreciate the coordination of all the presenters and their consistent message. It appears they took advantage of a "teachable moment" to show us true modeling of prevention by presenting a consistent message. The presenters touched on a number of common [themes]. The key points, especially from my perspective with a single State agency, include the following: (1) prevention has to be about what works; we need to replace ideology with science; (2) strategies must be long term, with booster sessions in following years; (3) there must be consistent messages beginning early with young children; (4) prevention must be culturally specific and must target all forms of drug abuse, not just single out one or two; (5) there is a need for parental involvement; (6) the problem is complex and its solution means a coming together of the biological and behavioral sciences; (7) tailoring of the programs is critical - something that is key to Missouri now.
In Missouri we often miss the boat by not putting the cards on the table and telling kids how they are influenced by their peers and the media. In my State of Missouri, Anheuser Busch represents a lot of liquor industry campaigning.
In regard to Dr. Botvin's presentation, I was impressed with the 40- to 75-percent initial reduction, the 6-year duration of results, and the use of booster sessions, which is something we have not done much with in our State. I will talk to the Missouri Department of Elementary and Secondary Education about the booster idea.
At some point I would like to address some programming specifics, that is, what might be contained in the teaching techniques with regard to instruction and reinforcement. Does that imply a consistent message - maybe in other parts of the school setting, in other curriculums, in the math classes, in science - or is it something entirely different?
I also was impressed with the discussion about barriers because sometimes we do not think about those, particularly barriers of lack of training, limited resources, and low teacher morale. With regard to the theme of starting prevention with younger children, I would also be interested in knowing whether this program has been replicated with children before they reach seventh grade.
In the area of additional resources, I would like to know more about the issue of parental involvement. In Missouri, many adolescents in treatment programs have a parent who taught them drug use in the home. This is further exacerbated by peers, the media, and other influences that teach that behavior. There is real significance in learning drug-use behavior at home, and I wonder whether something might be done in that area with additional resources.
I am excited about going back to Missouri and working with other organizations that we should have been working with all along. We address the community-based perspective, of which school is a big part, but we have been remiss at not integrating and making it a comprehensive approach with our education department. This as an opportunity to talk to our schools and our departments within State government.
Cecil Short
I have been a practicing administrator for more than 27 years and have an appreciation for this type of program, which heightens the awareness of school administrators. I represent an organization of more than 42,000 school administrators. My comments will be a commendation to Dr. Botvin for sharing his thoughts. I would also like to issue some challenges.
This is a drug culture. The term "the war on drugs," should probably be changed because the problem of drug use involves the human dynamic, not necessarily the military dynamic or related metaphors. On a national basis, I would challenge distinguished lecturers like Dr. Botvin to continue to espouse the message from the drug culture perspective, using the human dynamic.
Especially noteworthy in this discussion are drug resistance skills, because in my opinion, that is what it is all about from the school's perspective. I have not heard a presenter address drug resistance skills. At the secondary school level, we hear about students who are part of the drug culture at the elementary school level. That is frightening.
I challenge the speakers to involve other stakeholders in this drug culture. The primary stakeholder, as I heard this morning, centered around school personnel, but today we are dealing with young parents who cannot demonstrate the coping skills to meet the needs of their children, which is a different phenomenon. After having served as a school administrator for 27 years, I have come from a dynamic of disciplining children by just clearing my throat to having to send for a security guard. "Security guard" was not even in the vocabulary of the school adminis-trator 10 years ago. There is a different culture today.
I like the idea of social influences. The national slogan "Just Say No" will not do it for people who see a profit motive in the drug culture, and it will not work for a kid who makes more money in 1 week than the school principal. We have to do more than that. There has to be, in my judgment, treatment or exposure from a cultural health perspective.
I think we need to do more instruction in peer group types of environments, because the peer group does have a tremendous influence. Bringing youngsters into a classroom or an auditorium for a once-a-year program - and I have a great program, the DARE program - may not be making an impact.
I like the idea of peers. We need to find the peers of these youngsters and speak to them. More information should be given to the school personnel about drug resistance skills, comprehensive life skills, and the social influences approaches.
In closing, we have to be careful about the type of program approach that has a short shelf life. Every year there is a new paradigm shift and a new "alphabet soup." We need to have a program, run it from A to Z, and stay with it. If it is important, it ought to become a national movement, and everybody ought to line up behind it and march to the same drummer. We are in the parade, but some of us are marching to the beat of a different drummer.
Gilbert Botvin
Let me respond in the opposite order and pick up on some of the themes that Mr. Short mentioned, especially the last one, which resonated with me and which has concerned me for a long time. I said today and have said, humorously at times, in talking with various folks, that we have a real problem as a country. We have a national case of ADD, or attention deficit disorder. To some extent, the media may be more responsible than anyone else. Maybe the media, and not the public, are the ones with ADD.
Clearly, someone has difficulty paying attention to problems for a reasonable period of time. No sooner do we begin to work on solving one problem like drug abuse, teen pregnancy, or AIDS, than we are off to working on another problem. Almost every year there is a problem of the year. I think we need to get away from that mentality. We are going to make progress only if we consistently focus on these problems. We may need to focus simultaneously on many of these important public health problems, but clearly we have to set a national priority. We have to have an agenda that allows us to work on these problems until we can make some progress and not just bounce from one thing to another.
It is clearly important that we refocus the way in which we approach the problem of drug abuse prevention. This war on drugs metaphor has been an unfortunate one. I agree that it does not adequately capture the social aspects and the dimension of the problem.
What we are talking about is trying to develop interventions that deal with the whole kid, interventions that do not just teach kids to say "no" or beat them over the head with facts, but interventions that deal with real-life concerns and give kids the skills they need to succeed in a frequently hostile environment, whether it is at home, at school, or traveling to school. Unfortunately, many of our kids live in a hostile world. We need to give kids the skills to cope with that world and to succeed to the greatest extent possible. So we need to think about this in a different way. Hopefully, the kinds of messages coming out of this conference today will help us to see things in a somewhat different way.
Involving the various stakeholders is a real challenge to all of us who do research. We have one set of skills. We know how to do research. We know how to organize and conduct studies. We know how to distill the literature, develop theoretical models and intervention programs, conduct evaluations, and interpret the results. We even know how to write articles for scientific journals. But what we do not know how to do is talk about what we do in a way that is intelligible to people who have to go out and make a difference. We sit around at conferences and talk to one another and get excited about high P-
values and fancy multivariate statistics. But we are not saying the kinds of things that can make a difference in the real world. We have to move from our ivory tower situation to the real world and to talking with people like many of you here today who can make a difference in the real world.
We have talked at this conference about schools, but clearly there are other stakeholders and gatekeepers. We have formed alliances so we can all work together to see that proven prevention approaches get more widespread utilization. We need to involve not only the schools but also different groups in the community.
You are quite right that in many of the inner cities and in some rural populations parents are only a little bit older than the kids themselves. They do not have the skills. They may have problems of drug abuse. They may have a whole array of deficiencies with respect to many of the personal and social skills that we think are important. In those instances, we need to do more than just provide an intervention for the kids. We have to figure out ways of involving the family, getting them to have a stake in this, and helping them with their problems. There are many good family-level interventions that are currently being tested that can help to do that.
Our work only addresses kids in school, although we have made some efforts to involve the family and work with parents through videos and homework assignments. However, it is difficult in many situations to do a whole lot. If you come from a normal family, that is fine. If you come from a family like the one on television in "Third Rock From the Sun," which is a little bit wacky, that is something else. If you come from a family that is totally dysfunctional, where the parents are using drugs, that is a situation that almost seems entirely hopeless and clearly is difficult for us.
Even at our best, given the fancy statistics or the dramatic results that some programs produce, if drug use is cut in half, that is great, and we should all be excited about that. But that still leaves half the kids who are using drugs. Some kids may come from dysfunctional families or from families where one or both parents are using drugs. We may have a very hard time reaching those kids.
We clearly do not have the kinds of interventions that can make an impact on hardcore, high-risk kids; we need to do more work in those areas. We need to move beyond just saying "no"; that is not enough. That is one of the main messages I hope that you can take away from my talk this morning. You need to do more to reach out and work with the whole kid, because if we do not deal with their whole lives, if we do not give them the skills to cope with life and to succeed in the worlds in which they move, we are not going to have an impact on this great national tragedy that we see before us. I certainly agree with the importance of focusing on peer groups. In a lot of the work that we do, we attempt to work with kids within a group setting, utilizing peers and taking advantage of issues that may relate to peer socialization.
In response to some of the points raised by Ms. Haupt, it is important that we disseminate information about what works and the content of our prevention programs as well as about the way in which these programs can be implemented. There are various teaching techniques that can be used in prevention programs, and some of these techniques may be less effective than others. In our own work, building on work in some of the clinical areas, we have found that there are certain approaches to skills training and certain techniques that have been found to be helpful in past research.
We have imported those approaches that come from a clinical setting and have used them in what some people have referred to as this "psychoeducational program." For example, we are teaching kids skills for dealing with stress and anxiety and managing dysphoric feelings of depression. We are trying to teach these skills proactively so that kids have the ability to manage their own emotions, their own feelings, and the various issues that confront them. But we have to do that in a way that is going to be effective using the right techniques.
It is important to have reinforcement in all these programs; that is part of the importance of a booster intervention. However, in the kind of work that we have done, we have not had multiple levels or multiple channels of communication that would help us provide reinforcement of these various messages because of the nature of our intervention. Multichannel, multicomponent interventions are needed to provide various ways of reaching not only the children, through the schools, media, schoolwide support activities, and after-school programs, but also the parents - reach the kids by reaching the parents.
I wish I had an answer to your question of how we should deal with the many barriers. I do not have a great idea of what we can do to solve problems of inadequate resources or low teacher morale. I know what would help to change that, but I think you are talking about systemwide changes and no small amount of money that would be required to do that. You need to change the school environment, make it more user-friendly, make it a better place for kids, make it a better place at the same time for teachers, as well, so that they feel more empowered and enthusiastic about their work.
Many of the teachers in New York City who are hard-working, dedicated teachers have a hard time when there is no place for them or their students to sit. Those deplorable conditions have to change. It is difficult to learn and to conduct prevention programs under those conditions.
These barriers will take resources beyond those that are available, but there are things we can do to enhance the fidelity of implementation. One is to be careful in selecting teachers to implement programs like this. You need people who are enthusiastic, who want to be involved, and who do not have to have their arm twisted by the principal or the superintendent to do this.
A few years ago at the request of a school superintendent, I was giving a presentation to his principals about a program that we were about to conduct under some Federal funding. They were enthusiastic. Unfortunately, as it turned out, he was super-enthusiastic, and the more enthusiastic he became, the less enthusiastic they became. It turned out that there had been a history of
"labor/management difficulties" - bad communication, bad faith, and other problems. So this well-intended superintendent, who up until that point I had been thrilled with because he loved what we wanted to do and was very enthusiastic, did something that turned out to be irreparable and unforgivable. He essentially mandated the program for everybody. That became a kiss of death for us. In most situations, you cannot mandate programs and in this case, his enthusiasm and zealousness, although wonderful, turned out to be a problem for us.
You have to bring everybody along, and people have to have a sense of ownership about these programs if they are going to be involved and excited. You should select teachers who want to be involved, who do it voluntarily, who have good teaching skills, and who have good rapport with kids. Ideally, you want to get teachers who have high credibility with kids, who are even charismatic. They are great teachers, and they are going to do a great job in implementing the prevention program, even if they do not have any background in drug abuse prevention. You just need good people with good hearts who are committed. That is critically important.
It is also important to train teachers properly so they know what they are doing and why they are doing it and so they have a sense of hope and optimism. After doing this for many years, we are able to show teachers that this kind of program will make a difference if it is implemented properly. We give them data so they believe this can make a difference if they invest time and effort.
Teachers need training skills and opportunities to practice them in a workshop. Ideally, it is important to train a minimal number of people from the school district so that "lone rangers" are not the only ones conducting prevention programs. Training, selection, and ongoing support are critical components in dealing with the implementation fidelity problem.
The age of intervention is important. Many researchers believe that prevention should start as early as possible. In testing these programs, however, it is essential to start with an age group that can be followed within the confines of available funding and at a time when enough of them are beginning to engage in substance abuse or other behavior that can be evaluated and that results in reasonable and legitimate statistical comparisons. To start too early in a research study that may span 3, 4, or 5 years makes it impossible to do an evaluation. Therefore, work should be done with older populations. For many reasons, the middle or junior high school age group is important. It is a critical transition point and a critical risk period. For those reasons, this age group warrants our attention. It also is a time when the onset of drug use begins to rise more steeply. It is possible to demonstrate differences between treatment and control groups because the base drug use rates are sufficiently high in the seventh, eighth, and ninth grades.
Parent involvement is critically important. Although school-based intervention is the primary "workhorse," the centerpiece of most prevention efforts, the family must be involved. Although it is often difficult to involve busy parents or those with their own problems, we have to reach out. We need to develop more effective ways of reaching parents so that we have more comprehensive, multicomponent, multichanneled in- terventions. Only then can we have the kind of impact that we must have if we are going to prevent what is shaping up to be a major epidemic.
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