Richard C. Stephens

The Adolescent Substance Abuse Prevention Study: A randomized field trial of a universal substance abuse prevention program

OBJECTIVES The purpose of the study was to determine whether a universal school-based substance abuse prevention program, Take Charge of Your Life (TCYL), prevents or reduces the use of tobacco, alcohol, or marijuana. METHODS Eighty-three school clusters (representing school districts) from six metropolitan areas were randomized to treatment (41) or control (42) conditions. Using active consenting procedures, 19,529 seventh graders were enrolled in the 5-year study. Self-administered surveys were completed by the students annually. Trained Drug Abuse Resistance Education (D.A.R.E.) police officers presented TCYL in seventh and ninth grades in treatment schools. Analyses were conducted with data from 17,320 students who completed a baseline survey. Intervention outcomes were measured using self-reported past-month and past-year use of tobacco, alcohol, and marijuana when students were in the 11th grade. RESULTS Main effect analyses show a negative program effect for use of alcohol and cigarettes and no effect for marijuana use. Subgroup analyses indicated that the negative effect occurred among nonusers at baseline, and mostly among white students of both genders. A positive program effect was found for students who used marijuana at baseline. Two complementary papers explore the relationship of the targeted program mediators to the use of alcohol, tobacco, and marijuana and specifically for students who were substance-free or who used substances at baseline. CONCLUSIONS The negative impact of the program on baseline nonusers of alcohol and tobacco indicate that TCYL should not be delivered as a universal prevention intervention. The finding of a beneficial effect for baseline marijuana users further supports this conclusion. The programmatic and methodological challenges faced by the Adolescent Substance Abuse Prevention Study (ASAPS) and lessons learned offer insights for prevention researchers who will be designing similar randomized field trials in the future.

Drugs and Prisoners: Treatment Needs on Entering Prison*

An interview study was conducted among a group of incoming prisoners in a county jail in Ohio during the summers of 1997 and 1998 to assess their current drug treatment needs. “Incoming prisoners” refers to individuals who were being transferred from this county jail to the state prison system. Marijuana and cocaine were the most commonly tried illegal drugs among the subjects as well as the drugs of choice during the month prior to imprisonment. The Diagnostic Interview Schedule, combined with questions employed in the Drug Use Forecasting (DUF) project, was used to construct the questionnaire for this study. Based on the criteria of DSM-IV diagnoses, 57.5% of those interviewed had exhibited drug dependency at some point in their lives, and 51% were currently dependent on some substance. Thus, more than half of the incoming prisoners were in need of treatment for use of at least one substance. Cocaine dependence was the greatest problem facing this group of inmates, with an especially notable problem among the older females. Younger males were more likely to have current marijuana dependence. The study found that individuals currently dependent on cocaine or opiates perceived that they had a need for drug treatment, while those currently dependent on marijuana did not share this perception.

Effectiveness of HIV/AIDS Interventions on Drug Use and Needle Risk Behaviors for Out-of-Treatment Injection Drug Users

Abstract-This study presents an evaluation of the effectiveness of the AIDS Community-Based Outreach/Intervention projects implemented as part of the National Institute on Drug Abuse (NIDA) Cooperative Agreement (CA), which began in 1990 and is currently ongoing. Participants in the CA were randomly assigned to one of two interventions: a NIDA/CA-developed standard intervention (SI); or the SI plus a site-specific enhanced intervention (EI). Analyses of drug use and needle-related risk behaviors were conducted among injection drug users (IDUs) in eight participating cities where follow-up rates of at least 60% were obtained (N=3,743). Results indicated that IDUs significantly reduced their needle-related risk behaviors following delivery of the interventions and that a substantial portion entered substance abuse treatment. However, there was relatively little to support the effectiveness of more expensive and involved enhanced interventions. A number of factors associated with increasing or maintaining high risk behaviors, including an HIV negative serostatus and a greater perceived chance of acquiring AIDS, were also observed. Continued outreach to drug injectors is recommended, as well as the development of new and creative interventions targeting individuals who are HIV negative and those who are aware of their high risk status but have not changed their behaviors in response to risk-reduction interventions.

Universal school-based substance abuse prevention programs: Modeling targeted mediators and outcomes for adolescent cigarette, alcohol and marijuana use

OBJECTIVE We examined the relationships among targeted constructs of social influences and competence enhancement prevention curricula and cigarette, alcohol and marijuana use outcomes in a diverse sample of high school students. We tested the causal relationships of normative beliefs, perceptions of harm, attitudes toward use of these substances and refusal, communication, and decision-making skills predicting the self-reported use of each substance. In addition, we modeled the meditation of these constructs through the intentions to use each substance and tested the moderating effects of the skills variables on the relationships between intentions to use and self-reported use of each of these substances. METHODS Logistic regression path models were constructed for each of the drug use outcomes. Models were run using the Mplus 5.0 statistical application using the complex sample function to control for the sampling design of students nested within schools; full information maximum likelihood estimates (FIML) were utilized to address missing data. RESULTS Relationships among targeted constructs and outcomes differed for each of the drugs with communication skills having a potentially iatrogenic effect on alcohol use. Program targets were mediated through the intentions to use these substances. Finally, we found evidence of a moderating effect of decision-making skills on perceptions of harm and attitudes toward use, depending upon the outcome. CONCLUSIONS Prevention curricula may need to target specific drugs. In addition to normative beliefs, perceptions of harm, and refusal and decision-making skills, programs should directly target constructs proximal to behavioral outcomes such as attitudes and intentions. Finally, more research on the effects of communication skills on adolescent substance use should be examined.

Implementation fidelity: the experience of the Adolescent Substance Abuse Prevention Study

While researchers have developed more effective programs and strategies to prevent the initiation of substance use and increasingly communities are delivering these interventions, determining the degree to which they are delivered as they were designed remains a significant research challenge. In the past several years, more attention has been given to implementation issues during the various stages of program development and diffusion. This paper presents the findings from a substudy of an evaluation of a newly designed middle and high school substance abuse prevention program, Take Charge of Your Life delivered by local Drug Abuse Resistance Education officer instructors. A key aspect of the study was to determine the extent to which implementation fidelity, using the measures of content coverage and appropriate instructional strategy, was associated with improvement in the program mediators of realistic normative beliefs, understanding the harmful effects of substance use and the acquisition of decision-making and resistance skills. Although it was found that higher fidelity was associated with better scores on some of the mediators, this was not a consistent finding. The mixed results are discussed within the context of the lesson activities themselves.

Brief Motivational Intervention to Reduce HIV Risk and to Increase HIV Testing Among Offenders Under Community Supervision

Risky drug- and sex-related behaviors put criminal offenders at high risk for HIV. Intervening with this population under supervision can potentially reduce risk. This study reports a randomized trial that examines the efficacy of brief negotiation interviewing (BNI) compared to usual education activities. BNI is a computerized, self-directed intervention that combines a short structured interview with a brief counseling session. The study examined whether BNI could decrease HIV risks and increase testing for HIV in a cohort of criminal-justice-involved clients. The trial randomly assigned 212 participants to experimental (108) and control (104) conditions. Interview data were collected at baseline and at 2-month follow-up. Results indicate that the BNI intervention group had a significantly higher rate of HIV testing and was more likely to consider behavioral changes.

Afrocentric treatment in residential substance abuse care. The Iwo San.

Alcohol and other drug treatment programs continue to report relatively low success rates among African-American participants. We propose that there is a need to consider treatment approaches that are more culturally competent. An Afrocentric paradigm is suggested and instituted as the central theme of a residential drug treatment program. Elements of an Afrocentric orientation and how these principles are used to guide the development of a treatment philosophy are discussed.

The influence of program mediators on eleventh grade outcomes for seventh grade substance users and nonusers

OBJECTIVES In their work examining the effects of the Take Charge of Your Life (TCYL) program, Sloboda and colleagues (This Issue) found that the TCYL program had significant positive effects on baseline marijuana users and significant negative effects on baseline nonusers of cigarettes and alcohol. METHODS Mediational analyses were used to understand why the program had these differential impacts on baseline users and nonusers. RESULTS Path models for binary outcomes revealed significant program impacts on marijuana normative beliefs and refusal skills. The treatment impacts were between 1.5 and 3 times larger for the baseline users than for nonusers. These direct effects of the program on normative beliefs and refusal skills mediated the treatment impact on use for baseline marijuana users. In contrast, the negative treatment effects on alcohol and cigarette use could not be explained by the programs targeted mediators (normative beliefs, refusal skills, consequences, attitudes and intentions). The direct effects of treatment on use for the baseline nonusers of cigarettes and alcohol remain unexplained. CONCLUSIONS Possible explanations for this pattern and implications for strengthening universal prevention programs that are delivered to both users and nonusers are discussed. The importance of mediational analyses for programs that show negative impacts, as well as for those that show positive impacts is stressed.

Research Note: An Empirical Study of Adolescent Student Attrition

Sample attrition, a major concern in any longitudinal study, is even more problematic when adolescents are the study population. The need to minimize the loss of participants in order to maintain the integrity of the cohort is vital in substance abuse prevention evaluations. The Adolescent Substance Abuse Prevention Study (ASAPS), a national school based prevention study being conducted in six sites across the country, followed students attending schools randomly assigned to either a treatment or control condition from the seventh through the eleventh grade. The percent of study dropouts after the ninth grade pretest warranted consideration of an attrition study to acquire data from those students who were no longer in a study school. A pilot study conducted with a sample of attrition cases in one site (51 of 495) was undertaken to assess the feasibility and costs of a full study. This paper describes the experiences gained from this pilot study in tracking study subjects. An exhaustive protocol was developed and contacts with parents were initiated through telephone calls and flyers sent by mail. Online public records and telephone directories were used to acquire additional contact information. Contact was established with 56.8% of the parents and resulted in completed surveys from 19.6% of the sample at a cost of

The Value of Children, Parenting Strains, and Depression Among Urban African American Mothers

1,949.30 per survey.