2 Principles of Prevention Prevention programs should enhance protective factors and reverse or reduce risk factors (Hawkins et al. 2002). The risk of becoming a drug abuser involves the relationship among the number and type of risk factors (e.g., deviant attitudes and behaviors) and protective factors (e.g., parental support). The potential impact of specific risk and protective factors changes with age. For example, risk factors within the family have greater impact on a younger child, while association with drug-abusing peers may be a more significant risk factor for an adolescent. Early intervention with risk factors (e.g., aggressive behavior and poor self-control) often has a greater impact than later intervention by changing a child s life path (trajectory) away from problems and toward positive behaviors. While risk and protective factors can affect people of all groups, these factors can have a different effect depending on a person s age, gender, ethnicity, culture, and environment.
3 Principles of Prevention Prevention programs should address all forms of drug abuse, alone or in combination, including the underage use of legal drugs (e.g., tobacco or alcohol); the use of illegal drugs (e.g., marijuana or heroin); and the inappropriate use of legally obtained substances (e.g., inhalants), prescription medications, or overthe-counter drugs (Johnston et al. 2002). Prevention programs should address the type of drug abuse problem in the local community, target modifiable risk factors, and strengthen identified protective factors (Hawkins et al. 2002).
4 Principles of Prevention Prevention programs should be tailored to address risks specific to population or audience characteristics, such as age, gender, and ethnicity, to improve program effectiveness (Oetting et al. 1997). Family-based prevention programs should enhance family bonding and relationships and include parenting skills; practice in developing, discussing, and enforcing family policies on substance abuse; and training in drug education and information (Ashery et al. 1998). Prevention programs can be designed to intervene as early as preschool to address risk factors for drug abuse, such as aggressive behavior, poor social skills, and academic difficulties (Webster-Stratton 1998; Webster-Stratton et al. 2001). ).
5 Principles of Prevention Prevention programs for elementary school children should target improving academic and social-emotional learning to address risk factors for drug abuse, such as early aggression, academic failure, and school dropout. Education should focus on the following skills (Ialongo et al. 2001: self-control; emotional awareness; communication; social problem-solving; and academic support, especially in reading.
6 Principles of Prevention Prevention programs for middle or junior high and high school students should increase academic and social competence with the following skills (Botvin et al.1995; Scheier et al. 1999): study habits and academic support; communication; peer relationships; self-efficacy and assertiveness; drug resistance skills; reinforcement of antidrug attitudes; and strengthening of personal commitments against drug abuse.
7 Principles of Prevention Prevention programs aimed at general populations at key transition points, such as the transition to middle school, can produce beneficial effects even among high-risk families and children. Such interventions do not single out risk populations and, therefore, reduce labeling and promote bonding to school and community (Botvin et al. 1995; Dishion et al. 2002). Community prevention programs that combine two or more effective programs, such as family-based and school-based programs, can be more effective than a single program alone (Battistich et al. 1997). Community prevention programs reaching populations in multiple settings for example, schools, clubs, faith-based organizations, and the media are most effective when they present consistent, community-wide messages in each setting (Chou et al. 1998).
8 Principles of Prevention When communities adapt programs to match their needs, community norms, or differing cultural requirements, they should retain core elements of the original research-based intervention (Spoth et al. 2002b), which include: Structure (how the program is organized and constructed); Content (the information, skills, and strategies of the program); and Delivery (how the program is adapted, implemented, and evaluated). Prevention programs should be long-term with repeated interventions (i.e., booster programs) to reinforce the original prevention goals. Research shows that the benefits from middle school prevention programs diminish without followup programs in high school (Scheier et al. 1999).
9 Principles of Prevention Prevention programs should include teacher training on good classroom management practices, such as rewarding appropriate student behavior. Such techniques help to foster students positive behavior, achievement, academic motivation, and school bonding (Ialongo et al. 2001). Prevention programs are most effective when they employ interactive techniques, such as peer discussion groups and parent role-playing, that allow for active involvement in learning about drug abuse and reinforcing skills (Botvin et al. 1995). Research-based prevention programs can be cost-effective. Similar to earlier research, recent research shows that for each dollar invested in prevention, a savings of up to $10 in treatment for alcohol or other substance abuse can be seen (Pentz 1998; Hawkins 1999; Aos et al. 2001; Spoth et al. 2002a).
10 Risk Factors and Protective Factors Studies over the past two decades have tried to determine the origins and pathways of drug abuse and addiction how the problem starts and how it progresses. Many factors have been identified that help differentiate those more likely to abuse drugs from those less vulnerable to drug abuse. Factors associated with greater potential for drug abuse are called risk factors, while those associated with reduced potential for abuse are called protective factors. Please note, however, that most individuals at risk for drug abuse do not start using drugs or become addicted. Also, a risk factor for one person may not be for another. Risk and protective factors can affect children in a developmental risk trajectory, or path. This path captures how risks become evident at different stages of a child s life. For example, early risks, such as out-of-control aggressive behavior, may be seen in a very young child. If not addressed through positive parental actions, this behavior can lead to additional risks when the child enters school. Aggressive behavior in school can lead to rejection by peers, punishment by teachers, and academic failure. Again, if not addressed through preventive interventions, these risks can lead to the most immediate behaviors that put a child at risk for drug abuse, such as skipping school and associating with peers who abuse drugs. In focusing on the risk path, research-based prevention programs can intervene early in a child s development to strengthen protective factors and reduce risks long before problem behaviors develop.
11 Risk Factors and Protective Factors Risk Factors Domain Protective Factors Early Aggressive Behavior Lack of Parental Supervision Individual Family Impulse Control Parental Monitoring Substance Abuse Peer Academic Competence Drug Availability School Antidrug Use Policies Poverty Community Strong Neighborhood Attachment
12 What are the early signs of risk that may predict later drug abuse? Some signs of risk can be seen as early as infancy. Children s personality traits or temperament can place them at increased risk for later drug abuse. Withdrawn and aggressive boys, for example, often exhibit problem behaviors in interactions with their families, peers, and others they encounter in social settings. If these behaviors continue, they will likely lead to other risks. These risks can include academic failure, early peer rejection, and later affiliation with deviant peers, often the most immediate risk for drug abuse in adolescence. Studies have shown that children with poor academic performance and inappropriate social behavior at ages 7 to 9 are more likely to be involved with substance abuse by age 14 or 15.
13 In the Family Children s earliest interactions occur within the family and can be positive or negative. For this reason, factors that affect early development in the family are probably the most crucial. Children are more likely to experience risk when there is: lack of mutual attachment and nurturing by parents or caregivers; ineffective parenting; a chaotic home environment; lack of a significant relationship with a caring adult; and a caregiver who abuses substances, suffers from mental illness, or engages in criminal behavior.
14 In the Family These experiences, especially the abuse of drugs and other substances by parents and other caregivers, can impede bonding to the family and threaten feelings of security that children need for healthy development. On the other hand, families can serve a protective function when there is: a strong bond between children and their families; parental involvement in a child s life; supportive parenting that meets financial, emotional, cognitive, and social needs; and clear limits and consistent enforcement of discipline.
15 In the Family Finally, critical or sensitive periods in development may heighten the importance of risk or protective factors. For example, mutual attachment and bonding between parents and children usually occurs in infancy and early childhood. If it fails to occur during those developmental stages, it is unlikely that a strong positive attachment will develop later in the child s life.
16 Outside the Family Other risk factors relate to the quality of children s relationships in settings outside the family, such as in their schools, with their peers, teachers, and in the community. Difficulties in these settings can be crucial to a child s emotional, cognitive, and social development. Some of these risk factors are: inappropriate classroom behavior, such as aggression and impulsivity; academic failure; poor social coping skills; association with peers with problem behaviors, including drug abuse; and misperceptions of the extent and acceptability of drugabusing behaviors in school, peer, and community environments.
17 Outside the Family Association with drug-abusing peers is often the most immediate risk for exposing adolescents to drug abuse and delinquent behavior. Research has shown, however, that addressing such behavior in interventions can be challenging. For example, a recent study (Dishion et al. 2002) found that placing high-risk youth in a peer group intervention resulted in negative outcomes. Current research is exploring the role that adults and positive peers can play in helping to avoid such outcomes in future interventions. Other factors such as drug availability, drug trafficking patterns, and beliefs that drug abuse is generally tolerated are also risks that can influence young people to start to abuse drugs.
18 Family Family has an important role in providing protection for children when they are involved in activities outside the family. When children are outside the family setting, the most salient protective factors are: age-appropriate parental monitoring of social behavior, including establishing curfews, ensuring adult supervision of activities outside the home, knowing the child s friends, and enforcing household rules; success in academics and involvement in extracurricular activities; strong bonds with prosocial institutions, such as school and religious institutions; and acceptance of conventional norms against drug abuse.
19 What are the highest risk periods for drug abuse among youth? Research has shown that the key risk periods for drug abuse occur during major transitions in children s lives. These transitions include significant changes in physical development (for example, puberty) or social situations (such as moving or parents divorcing) when children experience heightened vulnerability for problem behaviors. The first big transition for children is when they leave the security of the family and enter school. Later, when they advance from elementary school to middle or junior high school, they often experience new academic and social situations, such as learning to get along with a wider group of peers and having greater expectations for academic performance. It is at this stage early adolescence that children are likely to encounter drug abuse for the first time.
20 What are the highest risk periods for drug abuse among youth? Then, when they enter high school, young people face additional social, psychological, and educational challenges. At the same time, they may be exposed to greater availability of drugs, drug abusers, and social engagements involving drugs. These challenges can increase the risk that they will abuse alcohol, tobacco, and other drugs. A particularly challenging situation in late adolescence is moving away from home for the first time without parental supervision, perhaps to attend college or other schooling. Substance abuse, particularly of alcohol, remains a major public health problem for college populations.
21 What are the highest risk periods for drug abuse among youth? When young adults enter the workforce or marry, they again confront new challenges and stressors that may place them at risk for alcohol and other drug abuse in their adult environments. But these challenges can also be protective when they present opportunities for young people to grow and pursue future goals and interests. Research has shown that these new lifestyles can serve as protective factors as the new roles become more important than being involved with drugs. Risks appear at every transition from early childhood through young adulthood; therefore, prevention planners need to consider their target audiences and implement programs that provide support appropriate for each developmental stage. They also need to consider how the protective factors involved in these transitions can be strengthened.
22 When and how does drug abuse start and progress? Studies such as the National Survey on Drug Use and Health, formerly called the National Household Survey on Drug Abuse, reported by the Substance Abuse and Mental Health Services Administration, indicate that some children are already abusing drugs by age 12 or 13, which likely means that some may begin even earlier. Early abuse includes such drugs as tobacco, alcohol, inhalants, marijuana, and psychotherapeutic drugs. If drug abuse persists into later adolescence, abusers typically become more involved with marijuana and then advance to other illegal drugs, while continuing their abuse of tobacco and alcohol. Studies have also shown that early initiation of drug abuse is associated with greater drug involvement, whether with the same or different drugs. Note, however, that both one-time and long-term surveys indicate that most youth do not progress to abusing other drugs. But among those who do progress, their drug abuse history can vary by neighborhood drug availability, demographic groups, and other characteristics of the abuser population. In general, the pattern of abuse is associated with levels of social disapproval, perceived risk, and the availability of drugs in the community.
23 When and how does drug abuse start and progress? Scientists have proposed several hypotheses as to why individuals first become involved with drugs and then escalate to abuse. One explanation is a biological cause, such as having a family history of drug or alcohol abuse, which may genetically predispose a person to drug abuse. Another explanation is that starting to abuse a drug may lead to affiliation with more drug-abusing peers which, in turn, exposes the individual to other drugs. Indeed, many factors may be involved.
24 When and how does drug abuse start and progress? Different patterns of drug initiation have been identified based on gender, race or ethnicity, and geographic location. For example, research has found that the circumstances in which young people are offered drugs can depend on gender. Boys generally receive more drug offers and at younger ages. Initial drug abuse can also be influenced by where drugs are offered, such as parks, streets, schools, homes, or parties. Additionally, drugs may be offered by different people including, for example, siblings, friends, or even parents.
25 When and how does drug abuse start and progress? While most youth do not progress beyond initial use, a small percentage rapidly escalate their substance abuse. Researchers have found that these youth are the most likely to have experienced a combination of high levels of risk factors with low levels of protective factors. These adolescents were characterized by high stress, low parental support, and low academic competence.
26 When and how does drug abuse start and progress? However, there are protective factors that can suppress the escalation to substance abuse. These factors include self-control, which tends to inhibit problem behavior and often increases naturally as children mature during adolescence. In addition, protective family structure, individual personality, and environmental variables can reduce the impact of serious risks of drug abuse. Preventive interventions can provide skills and support to high-risk youth to enhance levels of protective factors and prevent escalation to drug abuse.
Acknowledgments NIDA wishes to thank the following individuals for their guidance and comments during the development and review of this publication: Karen L. Bierman, Ph.D. Pennsylvania State University
Acknowledgments NIDA wishes to thank the following individuals for their guidance and comments during the development and review of this publication: Karen L. Bierman, Ph.D. Pennsylvania State University
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