School-based programmes to reduce and prevent substance use in different age groups: What works for whom?

This article summarises the following original research paper: Onrust S, Otten R, Lammers J et al. (2016) School-based programmes to reduce and prevent substance use in different age groups: What works for whom? Systematic review and meta-regression analysis. Clinical Psychology Review 44: 45–59.

Introduction

Substance use at a young age is associated with an increased risk of substance use disorders later in life and mental health problems (DeWit et al., 2000; Gil et al., 2004).

There are a large range of school-based preventive programmes that focus on tobacco, alcohol and drugs. However, results from previous systematic reviews and meta-analyses of substance use prevention programmes are inconclusive. The authors hypothesise that this may be due to the absence of a developmental perspective that considers the psychological and cognitive needs and capacities of children at various ages.

Taking a developmental perspective on substance use, the aim of this study was to examine the age-specific effectiveness for different aspects of school-based prevention programmes, including elementary school children, early adolescents, middle adolescents and late adolescents (in the UK, these categories equate to 6-11 years, 11-13 years, 13-15 years, 15-18 years).

What is the research underpinning it?

Studies evaluating behavioural outcomes in smoking, alcohol use and drug use were included in the review. To be eligible for inclusionAn approach where a school aims to ensure that all children are educated together, with support for those who require it to access the full curriculum and contribute to and participate in all aspects of school life, the intervention had to be compared with a control group of students who didn’t receive the intervention and the study had to report sufficient data to enable effect sizes to be calculated. Studies with missing data were therefore excluded from the analysis, which may have influenced the findings. 286 publications were included in the analyses. These reported on 288 programmes with a total of 436,180 participants. Programme characteristics were coded by two independent researchers with very high, meaning there was a high level of agreement between the researchers. Meta-regression analysis was used to analyse the associations between effects and programme characteristics. Meta-regression is a statistical method that is an extension to a  .

The findings support the hypothesis that specific aspects of the school-based programmes are effective in some developmental stages, but not for other age groups.

Elementary school children benefit most from enhancing personal competencies such as social skills, self-control and problem-solving skills, and healthy behaviours. Substance use prevention strategies, such as health education, preparing for social pressures to use substances and refusal skills training, were not effective. In elementary school, universal programmes (that target the general population, irrespective of risk status) are more effective than programmes targeting high-risk students (such as students from low socio-economic backgrounds or students with behavioural problems). Indeed, findings suggest that drawing attention to substance use for high-risk students can even be harmful in this developmental stage.

Early adolescents benefit most from targeting social norms, to correct misperceptions of peers’ substance use and acceptance-levels. This approach focuses on teaching students that substance use is not normal and that most early adolescents do not use substances. Social norm strategies that were related to positive results of universal programmes include feedback regarding peers’ actual and perceived substance use (normative feedback), stimulating students to make a public commitment not to use substances, mentoring and peer education. However, preparing students for peer pressure was not related to positive results. Conformity peeks in early adolescence, therefore instructing students not to conform to their peers might be less effective. Refusal skills training was marginally related to adverse outcomes of universal programmes as well as programmes for high-risk students. Parental involvement in universal prevention programmes can be an effective substance use prevention strategy in early adolescence, as is focusing on basic skills, such as self-control and decision making.

For middle adolescents, universal programmes are not very effective, with none of the selected substance use prevention strategies relating to more favourable results. A negative influence of refusal skills training was identified, which is perhaps unsurprising given that middle adolescents are extremely oriented on the needs, expectations, and opinions of their peers. High-risk students (who are already demonstrating substance use problems and are willing to change) benefit most from programmes that teach students to cope with stress and anxiety using techniques applied from cognitive behavioural therapy.

During late adolescence, opportunities for substance use prevention increase. Effective substance use prevention strategies in universal programmes include refusal skills training and health education on the interference of substance use with personal goals. This is in accordance with two primary developmental tasks of late adolescence, namely the formation of identity (with a reduced focus on the needs, expectations, and opinions of peers) and planning the future. Furthermore, basic skill training such as self-control and problem solving or decision making is also effective, which is in accordance with the developmental task of acquiring the necessary skills for the transition to adulthood. Finally, the involvement of parents can also result in more positive outcomes, as parent-adolescent relationships improve during this developmental stage. High-risk late adolescents also benefit from self-control training and the involvement of parents. However, refusal skills training is counterproductive for high-risk students, for whom programmes based on the transtheoretical model of behaviour change appear more appropriate. The authors give no further details about what this involves.

Impact on practice

The effectiveness of different substance use prevention strategies varies according to developmental stage, with some strategies even having a negative influence. This study highlights the importance of considering a developmental perspective when designing or choosing school-based substance use prevention programmes.

Key takeaways

• Results from previous systematic reviews and meta-analyses of substance use prevention programmes are inconclusive
• A developmental perspective on substance use considers the psychological and cognitive needs and capacities of the target groups
• Specific aspects of school-based programmes are effective in some developmental stages, but not for other age groups.

Want to know more?

The Association for Child and Adolescent Mental Health (Nd) Addiction & Substance Use.