Thursday, May 6, 2010

Adolescent Substance Use & D.A.R.E.: Kathy Vazquez

Introduction
According to the National Institute on Drug Abuse (NIDA), substance use is defined as “the use of illegal drugs or the inappropriate use of legal drugs” and substance abuse as “the repeated use of these drugs to produce pleasure, to alleviate stress, or to alter or avoid reality (or all three).”(1) Substance use has become a growing phenomenon among all populations in the United States primarily among adolescents. Today, nearly half of our youth have tried an illicit drug by the end of high school. (4) Adolescent substance use encompasses alcohol, legal and illegal drugs and the most recent trend of prescription medication. Substance use has significantly changed over the past generations when many drugs were more “natural”, less man-made and not as potent as they are today. Drugs today are combined with other chemicals and materials to increase their effect making every dose significantly more consequential than before. Prescription drug misuse is now second behind marijuana as the most prevalent drug problem in the United States. The National Survey on Drug Use and Health (NSDUH) reports national and state level data on the use of tobacco, alcohol, illicit drugs, and mental health among populations in the United States. (2) For 2008, the NSDUH reported an increase percentage of illicit substance use (marijuana, cocaine, heroin, hallucinogens, inhalants, and non-medical use prescription drugs) for that year as the age in adolescent increased: (3)
• 9% of 12 to 13 year olds
• 18% of 14 to 15 year olds
• 30% of 16 to 17 year olds
• 36% of 18 to 20 year olds
• 32% of 21 to 25 year olds
Substance use begins for most individuals during adolescence and because of the enormous changes that characterize this period of development, the severity at hand increases. The vulnerability in this population increases the risk drastically for substance abuse because of their immature brains, greater feelings of invincibility, lower sensitivity, and inability to foresee and contemplate consequences. Reported by the NSDUH’s Monitoring the Future- National Results on Adolescents Drug Use, adolescent determinants of substance use, characterized as the perceived benefits and the perceived risks, are often specific to the substance/ drug.(4) According to the report, “Word of the supposed benefits of using drug usually spreads much faster than information about the adverse consequences…thus, when a new drug comes onto the scene, it has a considerable ‘grace period’ during which its benefits are alleged and its consequences are not yet known.”(4)
Many public health campaigns and anti-drug approaches have attempted to prevent and reduce the incidence of substance use among adolescents. Several studies indicate that most drug abuse education programs have remained unsuccessful in reducing the incidence and rates of substance use among youth. Several campaigns have been well-recognized not only because of their popularity among school campuses but also because of their high rates of ineffectiveness, particularly the Drug Abuse Resistance Education Program (D.A.R.E) that many of us are quite too familiar with.
D.A.R.E. was created with the objective of preventing future substance use among adolescents as a response to the drug epidemic in the early 1980’s by the Los Angeles Police Department and the Los Angeles School District.(5) As the most widely used school-based drug use prevention program in the United States (used among over 80% of schools), D.A.R.E was implemented to teach children about the significance of abstaining from any substance use while at the same time increasing their life skills through self-esteem and reducing conformity. (5) D.A.R.E’s curriculum is most popularly known for its strong “no use” message, immediate consequences, normative beliefs, credible presenters (police officers), consequential thinking, protective factors-resiliency education, and interactive participatory learning. (5)
Based on the Social Influence Theory, D.A.R.E has emphasized the role and impact of social and psychological factors on the onset of substance use. (5) (6) The Social Influence Theory proposes that learning occurs in a social context where individuals observe one another and mirror or imitate what they have seen. (5) Adolescents model the social influences from mass media and peers to use drugs, drink alcohol, smoke, and engage in risky behaviors. Through D.A.R.E’s component of its strong “no use” message, the result of adolescent’s refraining from drug usage and being resilient was what was hoped to be expected, but the actual opposite occurred.
Regardless of D.A.R.E’s high expectations, studies have reported that the impact of preventing drug use among youth is quite low. Research has actually acknowledged that youth that have completed the program engaged in drug use at the same and at times higher rates than those that never participated (5). In this critique, I will address supported arguments that have led to the ineffectiveness of the D.A.R.E campaign and then present a proposed intervention with supported justifications.
Critique #1: Developmentally Inappropriate
The first issue I feel justifies the ineffectiveness of the D.A.R.E campaign is how developmentally inappropriate the program’s curriculum is. As previously stated, the adolescent brain is immature. This is associated with poor judgment, impulsivity, and inability to contemplate consequences. These characteristics differ greatly depending on the developmental stage an adolescent is in and different approaches are needed to effectively execute learning. According to Youth Violence: A report of the Surgeon General, “D.A.R.E is implemented too early in child development: It is hard to teach children who have not gone through puberty how to deal with the peer pressure to use drugs that they will encounter in middle school.” (7) Many critics introduce the issue that the information that is being presented is better suited for older children rather than the prime audience of 5th graders and because of this mismatch, children are unable to comprehend and analyze the issue. What is taught to high school students is very different from what should be taught to 5th graders and middle school students. The D.A.R.E program did not make this distinction.
Several theories of child development such as the Biological-Maturation Theory, the Behaviorist Theory, the Cognitive Development Theory, and the Socio-cultural theory all present different angles of the collaborative consideration of the developmental process with child learning. For example, Jean Piaget’s Cognitive Development Theory hypothesizes that there are discrepancies in the way a young child thinks compared to the way an older adolescent thinks because of different assimilation and accommodation opportunities they have each experienced. (8) These opportunities influence their developmental stages they are currently in and the next ones they will proceed towards. An individual’s capacity for complex thinking, understanding, and comprehension are developed as they progress through these stages. A 5th grader and a high school student are at different stages and differentiated techniques and approaches need to be implemented for an effective campaign.
As youth progress through adolescence, there are expected developmental tasks that need to occur but they each occur at discrete times during adolescence. For example, 5th graders are in the early stages of developmental progress that is characterized by dealing with physical changes and an increase in cognitive ability. This is also a time when children are very self-centered where the “world revolves around them.” In contrast, an adolescent in the later years of high school are progressing through the later tasks of development such as establishing autonomy, self-control, and the ability for reflection.
This is clearly assumed and recognized by Erik Erikson’s Theory of Psycho-Social Development that articulates an individual’s progress through eight developmental stages that contribute to one’s personality and psycho-social development. (9) Developmentally appropriate curriculums are integral in providing competent and effective preventative efforts for substance use among adolescents because as Erikson states, “Growth consists of a series of challenges…each successive step is a potential crisis because of a radical change in perspective…different capacities used different opportunities to become full-grown components of the ever-new configuration that is the growing personality.” (10)
Critique #2: “Just Say No” Irrationality
As seen with the traditional behavioral models such as the Health Belief Model and the Theory of Reasoned Action, the D.A.R.E campaign assumes that adolescents make rational decisions. For example, D.A.R.E’s simplistic “Just Say No” slogan assumes that if a teen is at a party with several of his friends whom are smoking pot and passing joints, that the teen is going to easily say “no” when his turn comes around to take a puff. This is truly irrational thinking because it ignores contextual factors such as the environment, peer pressure and the sense of arousal that the teen is experiencing as they are placed on the “hot seat.”
According to Dan Ariely in Predictably Irrational, he examines results that show how people just simply do not realize how different their decision making capabilities change during a state of arousal. (11) An adolescent may promise to say no, in the classroom setting with the D.A.R.E facilitator, but they are less likely to hold up and keep that promise when they are in the hot/emotional stage. As Ariely states, “We need to explore the two sides of ourselves; we need to understand the cold state and the hot state; we need to see how the gap between the hot and cold states benefits our lives, and where it leads us stray.” As a participant in the D.A.R.E program, sitting in a classroom filled with other students your age being lectured about the dangers of engaging in risky behavior, an adolescent is experiencing the cold state of the equation which differs greatly from the hot state they experience in reality.
The “just say no” slogan also exhibits clearly a characteristic that predicts irrationality- the fundamental attribution error. Because the D.A.R.E campaign forgets about context, individual character and knowledge is overestimated (adolescents will easily say no in any situation). There is too much preaching and “pointing the finger.” This also exhibits somewhat of a “parenting” technique as the police officers are telling teens what is right from wrong and telling adolescents what they should and should not do -this push might also increase rebellion among adolescents rather than increase the resiliency that is expected.
Critique #3: Scare Tactic Focus over Actual Facts
The D.A.R.E campaign attempts to gain adolescent attention through exaggerating fear-arousal factors and not providing comprehensive actual facts. With an abstinence approach, D.A.R.E creates harmful stereotypes about those who do drugs which then creates a negative illusion. Time Magazine reported in a 2001 article that a weakness of the D.A.R.E initiative was “its panic-level assertions that ‘drug abuse is everywhere’…the hysteria implied in the anti-drug rhetoric were pushing students away.” (12) Making drugs seem more prevalent than what they actually are could potentially push kids to engage in drug use who desire to fit in. (12)
D.A.R.E also relies heavily in lumping the consequences of all drugs together instead of really individualizing each drug, therefore incorrect information is disseminated and taught. (12) According to NSDUH’s Monitoring the Future- National Results on Adolescents Drug Use report, “To a considerable degree, prevention must occur drug by drug, because people will not necessarily generalize the adverse consequences of one drug to the use of the other drugs.” (4)
As presented earlier, adolescent determinants of substance use, characterized as the perceived benefits and the perceived risks, are often specific to the substance/ drug they use. Several traditional behavioral models, such as seen with the Theory of Reasoned Action and the Theory of Planned Behavior, weigh the perceived benefits against the perceived costs as they are integral precedents in the determine of behavior. The D.A.R.E campaign completely ignores this perspective as it couples all consequences together, therefore, students do not learn about the individual consequences and levels for each drugs and the campaign misses the opportunity to influence the adolescent’s perceived benefits and costs that would affect the behavior outcome.
Proposed Intervention:
As studied, there are certainly several shortcomings in the D.A.R.E campaign that have been reported and evaluated repeatedly over the past two decades but D.A.R.E has proven to be successful in a few other areas. For example, D.A.R.E. has done a wonderful job in marketing its program to the schools, news, and the media. D.A.R.E’s promotional items (stickers, handbags, shirts, pencils, etc) have gained popularity among students and school officials.
My proposed intervention would include several components that already comprise the foundation of the D.A.R.E. program but I would instead use a different approach of disseminating the information. Rather than an abstinence approach with the goal of fear arousal to scare young people from not doing drugs, I would provide accurate information about the consequences and usage of substances. I would clearly differentiate the consequences and usage for both legal substances and illegal drugs. By understanding the exaggerated beliefs of adolescents (they believe that “everyone is doing drugs”), we can educate them and provide a developmentally appropriate intervention for prevention and harm reduction.
I would also propose, in reference to the marketing perspective of the campaign, to market a slogan/theme of empowerment and one that does not actually explicitly display or advertise the prevention of drugs or risky behaviors.
I would also suggest a third proposition which would include the narrowing of the focus of the curriculum to the immediate needs of the audience at the time. For example, in a community where there is an abnormally high prevalence of non-medical use of prescription drugs among high school students, I would tailor the information that will be taught to what is most important and critical at that time.
Defense of Intervention #1: Social Norms Marketing Approach
The traditional approach, as seen among several campaigns, particularly that of D.A.R.E, is in scaring our young population into abstaining from engaging in risky behaviors (such as substance use) by stereotyping and exaggerating consequences. This technique has proven to lose its credibility when these adolescents actually experience the opposite of what was being taught. Teens will say that “that never happened to me or my friends, so it isn’t that bad.” According to researcher Dr. David Hanson, “They come to realize that they have been misled, deceived, and even lied to about the consequences of alcohol consumption.” (13)
As seen through the Social Norms Marketing approach and according to Dr. H Wesley Perkins, “father of the social norms marketing”, correcting misconceptions can reduce the prevalence and incidence among adolescents and college students in engaging in risky behaviors such as alcohol consumption and substance use. (14) Through the inclusion and the dissemination of actual facts, rather than what we want kids to perceive and think about, we must differentiate between the consequences and use of legal substances and illegal drugs. Many adolescents have a huge misconception in believing that the majority of their peers either drink excessively or use drugs a lot more than what is actually occurring as reported by Dr. Perkins. (13) Adolescents then feel that they need to live up to this expectation because of the need to fit in and they begin to engage in substance use at an early age and at rates and levels excessively above the reality. Correcting and clearing these misconceptions by providing actual facts and putting everything out on the table will then make them realize that fewer students are using substances and they will then be less likely to engage in these risky behaviors.
Changing the reality of how something is viewed upon among a population by providing actual facts and clearing misconceptions through the social norms approach rather than the abstinence/scare tactic approach will provide a population change that can have lasting effects.
Defense of Intervention #2: Framing
How an intervention is framed clearly affects the effects of the results of a campaign. As many campaigns are, the D.A.R.E campaign was negatively framed. Because of D.A.R.E’s mass popularity, adolescents expect that they are going to be lectured on how drugs are bad and why you shouldn’t do them when the police officer first walks into the classroom. Teens become so quickly turned away by advertisements or marketing approaches that clearly depict this idea –such as D.A.R.E’s motto of “to resist drugs and violence.” D.A.R.E’s promotional items are embraced in a context of negativity and of what not to do. D.A.R.E has been framed as an approach to stop kids from engaging in risky behaviors and as many of us have experienced, kids do not like to be told what they should or should not be doing.
The issue of framing also correlates to the previous defense of providing concrete facts and clearing misconceptions about substance use among students. Changing D.A.R.E’s abstinence approach from this is right and this is wrong and don’t do drugs because that is bad- we can frame the approach to the issue of empowerment and in “being” the majority of the student’s who do not engage is substance use.
An example of this approach is that of The Eighty-Four movement led by young people in Massachusetts to resist influence from the tobacco companies as presented in class. Rather than taking the negative perspective such as D.A.R.E in marketing what kids “should be doing” and how they should not become a part of the substance use world, The Eight-Four campaign took the opposing approach to a much higher level by creating a more social norms perspective of actually becoming a part of something. Adolescents are more inclined to have a positive reaction when they have the opportunity to take part in something and becoming a part of a group that signifies and represents who they are rather than the opposite. Adolescents will then want to “fit in” and conform.
Defense of Intervention #3: Developmentally & Contextually Appropriate
Any intervention tailored to the youth and adolescent population, as several research studies have and continue to report on, should be developmentally and contextually appropriate for the population and audience that it is tailored to affect. Adolescence is a period of rapid, uncontrollable and unexpected changes and a period of heightened vulnerability. It is comprised of developmental stages that are crucial in the transition from adolescence into adulthood and if interventions and campaigns do not recognize this issue, this mismatch will have negative effects.
According to an article presenting the correlation between adolescence cognitive and affective development with behavioral outcomes, “…with respect to normative development…this framework is helpful in understanding age differences in judgment and decision making, in risk-taking and in sensation seeking.” (15) If tailoring the period of adolescence that is transitioning between 5th to middle school, because many believe, and as presented by child development researchers, that this population is too young to understand the issues with peer pressure/influence and drugs, an empowerment perspective should be initiated.
Tailoring the older high school group should then provide a harm-reduction approach as contextual factors play a heavier role and influence on opportunities for engaging in risky behavior.

Conclusion
Substance use is a growing phenomenon in the United States, primarily among our adolescent population. As campaigns continue to evolve in hopes of preventing substance use among teens, many have failed and a few have been counterproductive. One infamous, widely used campaign, D.A.R.E, has been proven ineffectively so. Through a developmentally inappropriate, irrational and scare tactic/ abstinence focus, D.A.R.E has had a minimal effect on preventing the rates of substance use among adolescents.
As D.A.R.E continues to be implemented in over 80% of school districts in the U.S., a new approach needs to be undertaken. The inclusion of behavioral and social science technique and theories that have been evaluated with effectiveness can provide an opportunity for an innovative approach. The proposed intervention described above, through a social norms marketing approach, a new approach in framing the marketing of the campaign and integrating developmentally and contextually appropriate curricula, will initiate a different means in the hopes of preventing substance use among the most vulnerable populations among us.

References
1 National Institute on Drug Abuse (NIDA). Glossary. [cited on 2010 April 19].
Available at: http://teens.drugabuse.gov/utilities/glossary.php
2 National Survey on Drug Abuse and Health. [cited on 2010 Aril 19]. Available at: http://nsduhweb.rti.org/
3 Substance Abuse and Mental Health Services Administration. NSDUA. 2008
[cited on 2010 April 19] : Available at: http://oas.samhsa.gov/nsduh.htm
4 Johnston, Lloyd D., O’Malley, Patrick M., Bachman, Jerald G., and Schulenberg, John E. Monitoring the future: National results on adolescent drug use. Overview of key findings 2007. National Institute on Drug Use. 2008. 1-69.
5 Swims, Khadijak D. Drug abuse resistance education is ineffective at preventing future drug use in adolescents. Grand Valley State University. 1-12.
6 Botvin, Gilbert J. Preventing drug abuse is schools: Schools and competence enhancement approaches targeting individual level etiological factors. 2000. Addictive Behaviors. 25(6):887-897.
7 Youth Violence: A Report of the Surgeon General. 2001.
8 Huitt, W. and Hummel, J. Piaget’s theory of cognitive development. 2003. Educational Psychology Interactive. Valdosta State University. [cited on 2010 April 21] Available at http://www.edpsycinteractive.org/topics/cogsys/piaget.html
9 Munley, Patrick H. Erik Erikson’s theory of psychosocial development and vocational behavior. 1975. Journal of Counseling Psychology. 22(4): 314-319
10 Erikson, Erik H. Identity and the Lifecycle. 1980. W.W. Norton and Company Inc.
11 Ariely, Dan. Predictably Irrational. 2009. Harper Collins Publisher. New York, New York.
12 Reaves, Jessica. Just say no to DARE. Time Magazine. 2001.
13 Hanson, David J. Social Norms Marketing: Facts and information. Alcohol: Problems and solutions. 1997-2009. [cited 2010 April 26]. Available at: http://www2.potsdam.edu/hansondj/YouthIssues/1119834534.html
14 Hanson, David J. A proven way to reduce alcohol abuse- Interview with Dr. H. Wesley Perkins. 1997-2009. [cited 2010 April 26] Available at: http://www2.potsdam.edu/hansondj/YouthIssues/1046263474.html
15 Steinberg, Laurence. Cognitive and affective development in adolescence. 2005. Trends in Cognitive Science. 9(2): 69-74.

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