General comments

There is a hierarchy of influence of power in peer social groups, with natural peer leaders possessing power to affect the choices of their peers. Peer leaders exert influence over their followers and, even in deviant peer groups, these leaders can be induced through extrinsic rewards that lead to intrinsic motives to influence their followers not to use drugs.

Table 1  Potential risk and protective factors clustered around family and other social groups (from Department of Health 2001)

Evidence identified by the HDA

Adolescent tobacco, alcohol and drug use: current findings (Windle and Windle, 1999)

• The Adolescent Transitions Program (ATP) is a targeted programme for adolescents at risk of developing behaviour problems and for their parents (Dishion and Andrews, 1995). The ATP intervention was effective in reducing the levels of negative engagement between mothers and their adolescent children during the intervention period. However, it had an effect on adolescents’ problem behaviours at school and on their smoking behaviours if they were included in either of the two adolescent conditions (ie adolescent-focused or parent plus adolescent).

Belcher H.M., Shinitzky H.E., (1998) Substance abuse in children. Archives of Pediatrics and Adolescent Medicine 152 (October):952-960

• This article presents risk factors for substance misuse (e.g. peer group, genetics, psychopathology, family and community environment) but only gives general suggestion of effectiveness and does not describe existing or potential campaigns, which specifically target the factors highlighted.

• Describes example programmes pre-school, elementary school, junior/senior high school, but does not provide an effective review. Primary references cited suggest that social development programmes effective for up to 4 years, although the intervention itself runs over 4 school years - need to know whether effects extend beyond participation.

• Programmes that reduce the influence of specific risk factors, e.g. environmental (disadvantaged area where drugs are readily available) & familial (children of drug using parents), are likely to be protective

• Advocates integration/modulation of existing programmes (e.g. DARE) within research/evidence framework. Puts forward a case for holistic programmes whose scope extends beyond drug-centred multicomponent schemes

Botvin G.J., (1999) Adolescent drug use prevention: Current findings and future direction. In: Glantz M.D., Hartel C.R., (eds) Drug abuse: origins and interventions. Washington DC, American Psychological Association

• Evidence of effectiveness exists for psychosocial school-based interventions (e.g. Life Skills Training), which has been shown to be effective for minority groups if some modifications were made (requires the needs assessment). However, effectiveness appears to be short lasting.

• Also, the length of an intervention needs careful thoughts and the implementation process need to be monitored. Emphasis placed on peer influence on drug using behaviours but does not discuss evidence that young people may select their peer group on the basis on existing drug use (shared/common behaviours).

• Normative education proposals problematic - relies on young people placing value in general population behaviours rather than that of immediate peer group, which will have affective significance.

• High-risk individuals may see benefit in behaving contrary to norm.

Other evidence:

Drug Abuse Prevention Through Family Intervention. NIDA Research Monograph, Number 177

·         Interventions designed for the family target risk and protective factors specific to the family context as well as interactions between the family and other contexts that may involve the child or have an impact on the child. Research has identified a number of family-level risk and protective factors associated with initiation of drug use (Kumpfer, Olds, Alexander, Zucker, and Gary, this volume). Specifically, studies show that the presence of substance abuse disorders among parents or other family members poses both genetic and social risks for children (Bry 1994; Dumka et al. 1995; Johnson and Montgomery 1989; Merikangas, Dierker, and Fenton, this volume; Van Hasselt et al. 1993). Other family risk factors include parental or sibling use of alcohol, tobacco, and other drugs; positive family attitudes toward and acceptance of substance use; lack of attachment to parents at any developmental stage; sexual or physical abuse; economic instability; and poor family management (Hawkins et al. 1992, 1985). Protective factors in the family include consistent and contingent discipline; a strong parent-child bond; high levels of supervision and monitoring; and parental warmth, affection, and emotional support (Ge et al. 1996; Hawkins et al. 1992). Dishion and colleagues (1988) have demonstrated the importance of the family as an intervention context by showing, in longitudinal and cross-sectional analyses of prevention interventions, that enhancing parenting behaviors that have been shown to be protective can have a positive influence on the child. Specifically, they demonstrated that skill in parental monitoring can be taught and that this skill is a viable method of preventing early-onset drug use in children. Additionally, research indicates that protective family factors can moderate the effects of risk factors. Specifically, Brook and colleagues (1990) found that the risk of associating with peers who use drugs was offset by protective family factors such as parent conventionality, maternal adjustment, and strong parent-child attachment. Their research stresses the importance of the ongoing role of the family in the socialization of children well into the adolescent years. Family prevention interventions have successfully used behavioral, affective, and cognitive approaches to target a variety of family behaviors. Among them are parent-child interaction strategies, communication skills, child management practices, and family management skills (Bry, Catalano, Kumpfer, Lochman, and Szapocznik, this volume). A major factor that distinguishes family-based prevention interventions with positive outcomes from other parenting programs is that, similar to successful school-based programming, they concentrate on skill development rather than on simply educating parents about appropriate parenting practices. Effective programs use interactive teaching strategies to present skills to parents and their children, allow for practices and feedback, assign homework, and then help family members refine skills that work and modify those that do not. Another factor that contributes to the success of family interventions is who participates. Family interventions may focus on the parents or child separately or on the family as a whole. Among the most innovative and effective are those interventions that include parents and children in individual and group training sessions. In these interventions, work is done individually with the parents and the children and then the entire family is brought together to practice the skills and strategies learned in the individual sessions. This approach may be complicated if parents divorce and remarry. For example, Collins and Shanahan (this volume) found it necessary to collect data from three families (the original nuclear and two stepfamilies) to gain a full picture of the whole family for one child.

• Although the number of research-based family prevention interventions is increasing, there are still relatively few that have been subjected to rigorous efficacy studies and even fewer that have subsequently been replicated with diverse populations under less controlled conditions. However, this is rapidly changing, and many advances are being made. Currently there are universal, selective, and indicated family-based programs in the field (Catalano, Kosterman, Haggerty, Hawkins, and Spoth, this volume; Institute of Medicine 1994; Kumpfer, this volume). Some programs that originally targeted one population have been modified for others. For example, the Strengthening Families Program was originally designed as an indicated intervention for parents on methadone maintenance (Kumpfer, this volume). It has now been adapted for universal audiences (Spoth, this volume) and for use in a variety of cultural and physical contexts.

From: Brenna H, Bry, Richard F. Catalano, Karol L. Kumpfer, John E. Lochman, and José Szapocznik (citation as above)

• The critical role of family factors is acknowledged in virtually every psychological theory of substance abuse (Brook et al. 1990; Bry 1983; Catalano and Hawkins 1996; Dembo et al. 1979; Dishion et al. 1988; Elliott et al. 1989; Hawkins et al. 1992; Jessor 1993; Kandel and Davies 1992; Kaplan and Johnson 1992; Kellam et al. 1983; Kumpfer 1987; Newcomb and Bentler 1989; Oetting and Lynch 1993; Wills et al. 1992). Nevertheless, only recently have research findings about family protective and risk factors been applied in prevention intervention research.

• Protective Family Factors -  Family factors that appear to inhibit substance abuse can be categorized into five broad characteristics or activities that take place both in the home and outside the home. Protective factors within the home include close, mutually reinforcing parent-child relationships (Brook 1993; Brook et al. 1984, 1990; Catalano et al. 1993; Dishion et al. 1988; Werner and Smith 1992). Positive discipline methods on the part of parents are also protective against substance abuse (Blocket al. 1988; Catalano et al. 1993; Dishion et al. 1988; Kellam et al. 1983). Protective factors outside the home include monitoring and supervision of children’s activities and relationships (Catalano et al. 1992; Chilcoat et al. 1995; Dishion et al. 1988; Ensminger 1990; Fletcher et al. 1995; Richardson et al. 1989; Smart and Gray 1979). Family involvement with and advocacy for the children outside of the home, such as at church and in school, also prove to be protective against substance abuse (Brunswick et al. 1992; Kandel and Davies 1992; Krohn and Thornberry 1993). Finally, parents’ taking initiative and seeking information and support for the benefit of their children is protective (Crockenberg 1981; Nye et al. 1995; Rhodes et al. 1992, 1994; Stack 1974). These protective factors appear to reduce adolescent substance abuse by establishing a parent-child relationship, from birth, within which parents exert strong positive influence by knowing what their children do day to day, by providing ample praise for their appropriate behaviors, and by constantly introducing them to and actively supporting their engagement in a variety of pleasurable alternatives to substance abuse.

• Family Risk Factors - On the other hand, there are other family factors that clearly increase the probability that a child will abuse substances. Parental rejection and neglect heighten the risk of substance abuse (Block et al. 1988; Shedler and Block 1990). Physical abuse, sexual victimization, and other exposure to violence greatly increase the probability of substance abuse (Briere 1988; Briere and Zaidi 1989; Burnam et al. 1988; Clayton 1992; Dembo et al. 1989, 1992; Miller et al. 1987; Polusny and Follette 1995; Rohsenow et al. 1988; Zierler et al. 1991). Finally, substance abuse by parents and siblings greatly increases the chance that children will abuse substances (Andrews et al. 1993; Brook et al. 1991; Dishion et al. 1988; Merikangas et al. 1992; Sher et al. 1991). In sum, these family risk factors seem to increase substance abuse by producing children with memories of rejection, pain, humiliation, and interpersonal conflict, while depriving them of the protective factors of interpersonal warmth, supervision, and positive guidance in effective life functioning. The unpleasantness in these children’s lives increases the reinforcing value of substance use, while the missing protective factors leave the children without viable, alternative methods to gain pleasure or relief from pain.