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Drug Abuse

Prevention
Drug Abuse

Prevention 

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Introduction

The National Institute on Drug Abuse (NIDA) supports most of the world’s research on drug abuse and addiction.

NIDA-funded research enables scientists to apply the most advanced techniques available to the study of every aspect of

drug abuse, including:

• genetic and social determinants of vulnerability and response to drugs;

• short- and long-term effects of drugs on the brain, including addiction;

• other health and social impacts of drug abuse, including infectious diseases and economic costs;

• development and testing of medications and behavioral treatments for abuse and addiction; and

• development and evaluation of effective messages to deter young people, in particular, from abusing drugs.

Included in this document are selections of topic-specific articles reprinted from NIDA’s research newsletter, 

NIDA NOTES. Six times per year, NIDA NOTES reports on important highlights from NIDA-sponsored research, 

in a format that specialists and lay readers alike can read and put to use. Selections like the current one are intended 

to remind regular NIDA NOTES readers and inform other readers of important research discoveries during the periods

they cover.

We hope the information contained here answers your needs and interests. To subscribe to NIDA NOTES and for further

information on NIDA’s drug abuse and addiction research, please visit our Web site at www.drugabuse.gov.
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Table of Contents

MTF Survey Finds Overall Decline in 

Teen Substance Abuse (V20-5; April 2006) . . . . . . . . . 1

NIDA Launches HIV/AIDS Public Awareness 

Campaign (V20-5; April 2006) . . . . . . . . . . . . . . . . . . 3

NIDA and Scholastic Offer Teens and Teachers 

New Heads Up (V20-4; March 2006) . . . . . . . . . . . . . . 4

Teen Access to Cigarettes Declining, But Still High 

(V20-4; March 2006) . . . . . . . . . . . . . . . . . . . . . . . . . . 5

HIV/AIDS Research and Education Are Crucial to 

Drug Abuse Prevention (V20-3; October 2005) . . . . . . 6

Exploring the Why’s of Adolescent Drug Abuse

(V19-3; September 2004) . . . . . . . . . . . . . . . . . . . . . . . 7

Web-Based Program Trains Practitioners To Add

Prevention Messages to Wellness Programs

(V19-3; September 2004) . . . . . . . . . . . . . . . . . . . . . . . 9

New Index Measures Self-Control, Predicts Drug Abuse

Vulnerability in Adolescent Boys (V19-2; July 2004) . . 11

School-Based Program Promotes Positive Behavior,

Reduces Risk Factors for Drug Use, Other Problems

(V18-6; February 2004) . . . . . . . . . . . . . . . . . . . . . . . 14

School Prevention Program Effective With Youths

at High Risk for Substance Use (V18-5; December

2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

NIDA-Funded Research Drives Revision of Guide to

Prevention Programming (V18-4; November 2003) . . 19

NIDA National Prevention Research Initiative Begins

Broad Range of Studies (V18-3; October 2003) . . . . . 20

Multiculturalism at Least as Effective as Cultural

Specificity in Test of Prevention Program

(V18-3; October 2003) . . . . . . . . . . . . . . . . . . . . . . . . 22

Relationships Matter: Impact of Parental, Peer

Factors on Teen, Young Adult Substance Abuse

(V18-2; August 2003) . . . . . . . . . . . . . . . . . . . . . . . . 25

Few Middle Schools Use Proven Prevention Programs

(V17-6; March 2003) . . . . . . . . . . . . . . . . . . . . . . . . . 28

Grouping High-Risk Youths for Prevention May

Harm More Than Help (V17-5; January 2003) . . . . . 30

Social Environment Appears Linked to Biological

Changes in Dopamine System, May Influence

Vulnerability to Cocaine Addiction

(V17-5; January 2003) . . . . . . . . . . . . . . . . . . . . . . . . 32

Youths’ Opportunities To Experiment Influence

Later Use of Illegal Drugs (V17-5; January 2003) . . . 34

Shortened Family Prevention Programs Yield LongLasting Reductions in Adolescent Drug Abuse

(V17-2; May 2002) . . . . . . . . . . . . . . . . . . . . . . . . . . 37

New Vistas in Drug Abuse Prevention 

(V16-6; February 2002) . . . . . . . . . . . . . . . . . . . . . . . 39

NIDA Conference Reviews Advances in Prevention

Science, Announces New National Research Initiative

(V16-6; February 2002) . . . . . . . . . . . . . . . . . . . . . . . 41

The Many Faces of MDMA Use Challenge 

Drug Abuse Prevention (V16-5; December 2001) . . . 44

Television Public Service Announcements 

Decrease Marijuana Use in Targeted Teens 

(V16-4; October 2001) . . . . . . . . . . . . . . . . . . . . . . . 46

NIDA Initiative Targets Increasing Teen Use of 

Anabolic Steroids (V15-3; August 2000) . . . . . . . . . . 47

Putting Science-Based Drug Abuse 

Prevention Programs to Work in Communities 

(V14-6; March 2000) . . . . . . . . . . . . . . . . . . . . . . . . . 49

Studying Comprehensive Drug Abuse Prevention

Strategies (V14-5; December 1999) . . . . . . . . . . . . . . 51

Student Use of Marijuana Linked to Perceptions 

of Risk (V14-4; November 1999) . . . . . . . . . . . . . . . . 52

Ethnic Identification and Cultural Ties May Help 

Prevent Drug Use (V14-3; September 1999) . . . . . . . 53

Steroid Prevention Program Scores With 

High School Athletes (V12-4; July/August 1997) . . . . 55

Specialized High School Prevention 

Programs Target At-Risk Adolescents 

(V12-3; May/June 1997) . . . . . . . . . . . . . . . . . . . . . . 58

Multifaceted Prevention Programs Reach 

At-Risk Children Through Their Families 

(V12-3; May/June 1997) . . . . . . . . . . . . . . . . . . . . . . 60

Research Meets the Challenge of Preventing 

Drug Use Among Young People 

(V12-3; May/June 1997) . . . . . . . . . . . . . . . . . . . . . . 63
MTF Survey Finds Overall Decline in Teen Substance Abuse

Research Findings

Volume 20, Number 5 (April 2006)

Substance abuse among teenagers in the United States

declined 19 percent over the past 4 years, with 15.8 percent reporting past-month abuse in 2005, compared with

19.4 percent in 2001, according to the latest Monitoring

the Future Survey. The nationwide survey of 8th-, 10th-,

and 12th-graders found that the overall decline was tempered by increases or unchanged rates of abuse of some

prescription drugs, inhalants, and other substances.

The 4-year decline has been driven largely by decreasing

rates of marijuana abuse. For example, since 2001, pastmonth abuse of marijuana fell by 28 percent among 8thgraders and by 23 percent among 10th-graders. Although

most year-to-year changes in the annual survey are not statistically significant, teen abuse of five substances—GHB,

LSD, MDMA/Ecstasy, methamphetamine, and steroids—

showed significant declines from 2004 to 2005.

The survey findings are encouraging because teenagers are

most vulnerable to the effects of drugs and youths who

abstain in their teen years are less likely to abuse drugs

later in life, NIDA Director Nora D. Volkow, M.D., 

says. She notes, however, that teens’ abuse of prescription

medications and inhalants has continued unabated in the

past few years. NIDA is particularly concerned about the

nonprescribed use of opioid painkillers, such as

OxyContin and Vicodin. In 2005, 9.5 percent of 12thgraders reported abusing Vicodin in the past year, and 5.5

percent reported OxyContin abuse, which has increased

more than one-third since 2002. “Using these drugs without a prescription is dangerous. It’s imperative that teens

get this message,” Dr. Volkow stresses.

Abuse of inhalants, which are found in common household substances such as nail polish remover, glue, and

cleaning fluids and are very toxic, also has been rising in

recent years. Abuse among eighth-grade students has

increased significantly since 2002, Dr. Volkow says.

Smoking Decline May Be Tapering Off

Dr. Lloyd Johnston of the University of Michigan, the

principal investigator of the study, notes a worrisome 

signal that the decline in smoking may be tapering off:

The smoking rate among eighth-graders held steady in the

1
latest survey, following a long-term decline over the past

several years. Eighth-graders are considered an important

bellwether of drug-related trends among teenagers.

Moreover, smoking declines in the upper grades also

slowed in 2005. Survey data do not indicate long-term

declines in the abuse of marijuana and other illicit drugs

among 8th-graders, and declines among 10th- and 12thgrade students were very modest, Dr. Johnston notes.

On the positive side, cigarette smoking is at its lowest rate

in the 30-year history of the survey. Also, the proportion

of eighth-graders reporting that they have ever tried to

smoke cigarettes declined in the latest survey, which could

reflect shifts in behaviors and intentions that occurred several years earlier. 

The survey covered about 50,000 students in more than

400 public and private schools. The University of

Michigan conducted the survey under a grant from

NIDA, the National Institutes of Health, and the

Department of Health and Human Services. Further

details on the survey are available at www.drugabuse.gov/

DrugPages/MTF.html and at monitoringthefuture.org. 

2
3

NIDA Launches HIV/AIDS Public Awareness Campaign

Research Findings

Volume 20, Number 5 (April 2006)

The link between drug abuse and HIV infection is the

focus of a new public awareness campaign launched by

NIDA on November 29, 2005. NIDA Director Nora D.

Volkow, M.D., announced the campaign and screened

“Text Message,” a new public service announcement

(PSA) aimed at teenagers, during a press conference at the

National Press Club in Washington, D.C. “Drug abuse

prevention is HIV prevention,” says Dr. Volkow. “In

recent years, the number of young people in the United

States diagnosed with AIDS rose substantially. Because

drug use encourages risky behaviors that can promote

HIV transmission, NIDA views drug abuse prevention

and treatment as essential HIV prevention.”

The PSA shows young women text messaging on cell

phones about a friend who contracted HIV after using

drugs and having sex at a party. The dialogue says, “She

got high, got stupid, and now she has HIV.” The

announcement is being aired on television stations across

the country.

The PSA was produced in collaboration with students

from the Duke Ellington School of the Arts, a

Washington, D.C., public high school. Students were

involved in developing the concept for the PSA and 

also performed the lead roles. The intent is to dispel the

myth that only intravenous drug abuse can lead to HIV

infection and to promote awareness of the consequences

of the risky sexual behavior that can follow any type of

drug abuse.

“Before working on the PSA, I was more concerned about

pregnancy as a result of unprotected sex than HIV infection, which seemed only to affect older people,” said

Ellington student Rebecca Hollingsworth. Research has

shown that this view is widespread: A large proportion 

of youths are not concerned about becoming infected 

with HIV, despite the fact that young people between 

the ages of 13 and 24 represent a growing percentage of

new infections.

NIDA has formed a coalition with organizations including

the American Academy of Child and Adolescent

Psychiatry; the AIDS Alliance for Children, Youth and

Families; and the United Negro College Fund Special

Programs Corporation to get this important message

about the link between drug abuse and HIV infection to

teenagers and young adults. In addition to the PSA, which

will be aired on television stations across the United

States, posters advertising NIDA’s message— “Drug Abuse

and HIV: Learn the Link”—will be displayed on public

transportation and buses in Washington, D.C., Chicago,

and Dallas.

NIDA’s public awareness campaign also includes a recently

launched Web site, www.hiv.drugabuse.gov, where visitors

can browse publications such as the new HIV/AIDS

Research Report, download the PSA, and read about the

latest scientific findings on the relationship between drug

abuse and HIV infection. 

An image from NIDA’s “Text Message” public service announcement
NIDA and Scholastic Offer Teens and 

Teachers New Heads Up

Research Findings

Volume 20, Number 4 (March 2006)

NIDA and Scholastic, Inc., have joined forces to produce

a third installment of the series Heads Up: Real News

About Drugs and Your Body. The new science-based articles

and vivid, informative graphics will be distributed to nearly 2 million middle and high school students via the pages

of Scholastic’s publications Junior Scholastic, Science World,

and Up Front. This year’s materials, which include a

teacher’s guide, once again strike the theme of the unique

dangers drugs pose to teens.

“Research indicates that adolescence, a time when many

changes are occurring in the brain, may be a period of significantly increased vulnerability to drugs’ effects,” says

NIDA Director Dr. Nora D. Volkow. By presenting

NIDA’s research in an accessible format, Heads Up speaks

directly to its youthful audience about issues including

HIV and drug abuse, the link between food cravings and

drug cravings, the health dangers of inhalants, and the

misuse of prescription drugs. 

Adolescents, AIDS, and Abuse: A Deadly Connection

Between 1998 and 2000, one of every six persons with a

newly diagnosed HIV infection was between the ages of

13 and 25. Along with injecting drugs, which 1 in 50

U.S. high school students report having done at least

once, drug-influenced bad judgments can lead to infection, and drugs can reduce the body’s ability to fight off

infection. “Teens, Drug Abuse, and AIDS: The Deadly

Connection” provides young people with the statistics and

scientific information they need to understand the potential health consequences of their decisions concerning

drugs and sexual relationships.

Linking Addictions to Food and Drugs

“Two Teen Health Dangers: Obesity & Drug Addiction”

tells readers how NIDA scientists discovered that cravings

for food and cravings for drugs have a common biological

basis in the brain. Both drug abusers and obese people

tend to have lower than average numbers of the brain proteins called dopamine receptors, a deficit that could limit

the amount of pleasure they gain from ordinary activities

and achievements. Overeating and drug abuse may be

attempts to compensate; both stimulate the dopamine 

system to higher activity levels. 

The article leads readers through the specific experiments

researchers conducted to find these connections and teaches

how to design a

scientific experiment and calculate their own

body mass

index. It points

out that people

can enhance

the brain’s

dopamine

activity without overeating or taking

drugs by

exercising

and spending

time with friends 

and family. 

Bucking the Trend: Increase in Inhalant and

Prescription Drug Abuse

The 2005 University of Michigan Monitoring the Future

(MTF) Survey found that the number of U.S. 8th-, 10th-,

and 12th-grade students who reported abusing drugs in

the past month dropped 19 percent from 2001 to 2005.

However, past-year inhalant abuse among eighth-graders

increased, and abuse of the prescription drugs oxycodone

(OxyContin) and hydrocodone (Vicodin) remained high.

“Abuse of Inhalants and Prescription Drugs: Real Dangers

for Teens” paints a vivid, realistic picture of these substances’ ill effects. Even in an otherwise healthy person, a

single session of abusing highly concentrated amounts of

certain inhalants can lower oxygen levels enough to cause

asphyxiation or disrupt heart rhythms and cause death

from cardiac arrest.

Prescription medication abuse can cause both short-term

and long-term health problems, from potentially fatal

overdose to addiction and long-term brain changes. In

addition to exposing the dangers of these substances, the

Heads Up article explains how the MTF Survey data were

collected and why these data are important in understanding and fighting drug abuse.

All Heads Up materials can be found at either 

www.drugabuse.gov/scholastic.html, or at Scholastic’s 

Web site, www.scholastic.com/headsup.

4
Teen Access to Cigarettes Declining, But Still High

Research Findings

Volume 20, Number 4 (March 2006)

Fewer underage teens bought cigarettes in 2002 than in

1997, but most still found the products easy to obtain,

according to the Monitoring the Future (MTF) Survey 

of 8th-, 10th-, and 12th-graders. Half the teens who said

they were current smokers reported personally buying 

cigarettes from a retail store, down about 5 percent from

1997; only one-third said they were asked to provide

proof of age during their last purchase. They most often

bought cigarettes at gas stations or convenience stores,

which have the highest rates of pro-tobacco advertising

and self-service access to tobacco products. Dr. Lloyd

Johnston and colleagues at the University of Michigan say

the findings suggest that some policies to limit access to

cigarettes by minors—for example, requiring clerk-assisted

purchases—may be having an impact, but also point 

to considerable retailer noncompliance with underage 

sales regulations. 

American Journal of Preventive Medicine 27(4):267-276,

2004. 

5
6

HIV/AIDS Research and Education Are

Crucial to Drug Abuse Prevention

Research Findings

Volume 20, Number 3 (October 2005)

Behavior associated with drug abuse is

the single largest factor in the spread

of HIV infection in the United States,

where about one-third of HIV/AIDS

cases are related to injection drug abuse. 

NIDA’s Web site, http://hiv.drug

abuse.gov, provides research-based information about

HIV/AIDS and its relationship to drug abuse. A compendium of NIDA publications and public service

announcements, the Web site is a valuable resource for

care providers as well as parents and teens looking for

information. Visitors to the site will find a list of drugs

that are commonly abused, a phone number and Web site

for treatment referrals, up-to-date research findings, and

announcements in English and

Spanish about special events. 

Using or sharing drug paraphernalia such as unsterile needles,

cotton swabs, rinse water, and

cookers to inject heroin, cocaine,

or other drugs places drug abusers

at risk for contracting or transmitting HIV. Drug abuse without

the use of needles and syringes

can also foster the spread of HIV.

Research sponsored by NIDA and

the National Institute on Alcohol

Abuse and Alcoholism has shown

that drug and alcohol use can

interfere with judgment about

sexual behavior and thereby affect

the likelihood of engaging in

unplanned and unprotected sex.

This increases the risk for contracting HIV from infected sex partners. 

In the past 15 years, NIDA has sponsored a comprehensive research program in response to the dynamic nature

of the co-occurring epidemics of drug abuse and

HIV/AIDS. This research has yielded science-based principles that should prove useful to community planners, 

policymakers, service providers, and medical practitioners

as they develop and implement programs to prevent the

spread of HIV and other infections among injecting and

noninjecting drug users and their sexual partners. To 

foster widespread use of these principles, NIDA has 

produced a number of publications, such as Principles of

HIV/AIDS Prevention in Drug-Using Populations and The

NIDA Community-Based Outreach Model: A Manual To

Reduce the Risk of HIV and Other Blood-Borne Infections 

in Drug Users.

The Web site also offers the “Jack & Jill” public service

announcements, which are geared toward teens and provide information about substance abuse and risky sexual

behavior. “Jack & Jill” was the first installment in NIDA’s

“Keep Your Body Healthy” campaign, and deals with the

connection between drug abuse and contracting

HIV/AIDS. It has been estimated that at least half of all

new HIV infections in the United States are among people under age 25, and most of these young people are

infected sexually.

NIDA’s Web sites, including http://hiv.drugabuse.gov, help

bring the Institute’s research and policies to a wide audience; by disseminating material online, parents, teens, and

providers have an accessible resource for the latest in drug

abuse research. 

Exposure 

category

Males Females Overall total

No. % No. % No. %

Male-to-Male 

Sexual Contact 384,784 55 — — 384,784 55

Injection Drug

Abuse 151,367 22 58,552 39 209,919 30

Heterosexual

Contact 36,692 5 63,379 42 100,071 14

Source: CDC. HIV/AIDS Surveillance Report: Cases of HIV infection and AIDS in the United

States, Vol. 14, 2002. Atlanta, Georgia: U.S. Department of Health and Human Services.

AIDS Cases By Exposure Category and Sex Through 2002
Exploring the Why’s of Adolescent Drug Abuse

By NIDA Director Nora D. Volkow, M.D. 

Research Findings

Volume 19, Number 3 (September 2004)

Adolescence and early adulthood are

periods of growth, exploration, and—

for some teens and young adults—the

development of drug abuse and addiction. Each day roughly 3,000 teens

smoke their first cigarette. Among

30,000 teenagers polled by the National

Survey on Drug Use and Health in

2002, 4.2 percent of 12- to 13-year-olds

reported using an illicit drug in the past

month, along with 11.2 percent of 14-

to 15-year-olds, 19.8 percent of 16- to

17-year-olds, and 22.5 percent of 18- to

20-year-olds. Data gathered in 2002 by

the Substance Abuse and Mental Health

Services Administration show that 64

percent of patients entering treatment

for drug abuse started abusing drugs at age 20 or younger.

Teen smoking illustrates the risks of early exposure to

addictive drugs. A third of high school students who try

smoking eventually become daily smokers. Young smokers

appear to be more vulnerable to nicotine addiction than

are older smokers; teen users report symptoms of dependence after smoking fewer cigarettes than adults, and they

have more difficulty quitting and experience more severe

withdrawal than adults who smoke similar amounts.

NIDA research is shedding light on the processes that

underlie the exceptional susceptibility to addiction experienced by boys and girls who begin using drugs in adolescence. Recent animal studies provide evidence that drugs

affect the developing brain differently than they do the

matured brain. In one study, rats exposed to nicotine in

adolescence self-administered more nicotine—as adolescents and as adults—than rats first exposed to nicotine in

adulthood. In another study, rats exposed to nicotine in

adolescence and given cocaine when they reached adulthood exhibited more sensitivity to cocaine’s stimulant

effects than did rats that were first exposed to both drugs

as adults (see “Early Nicotine Initiation Increases Severity

of Addiction, Vulnerability to Some Effects of Cocaine,”

NIDA NOTES, Vol. 19, No. 2).

To strengthen prevention and treatment of drug abuse and

addiction during the crucial adolescent period, NIDA has

initiated a three-pronged research effort. One component

of the effort will explore how developmental changes that occur in the adolescent brain may increase vulnerability to

drugs, and how drugs in turn may subvert normal neurobiological maturation.

We will increase support of animal

studies to ascertain the successive steps

in adolescent brain development and

whether they differ with abstention

from drugs, initiation of drug abuse,

escalation to uncontrollable abuse, and

relapse (RFA 04-011: “Animal Models

of Adolescent Drug Abuse: Integrative

Studies of Brain and Behavioral

Development”).

A second component of our initiative

aims to increase our ability to dissuade

teens from abusing drugs by focusing on the cognitive

processes—learning, motivation, judgment, and decision

making—that influence choices to abuse or avoid drugs

(RFA 04-009: “Behavioral and Cognitive Processes

Related to Adolescent Drug Abuse”). This research will

elucidate how teens perceive risk and make decisions on

matters that involve risk. It will address such questions as

why some young people engage in drug abuse when they

have received information regarding its destructive potential. Do they assess the risks inaccurately, or do they

understand the risks but weigh them more lightly than

do abstaining adolescents?

The third focus of NIDA’s new initiative is the period of

emerging adulthood, which spans the years from 18 to 25.

This is a time of continued brain development, but most

of all of new personal and social choices and challenges:

the emergence of personal beliefs and values, exploration

of career roles, and transitions involving increasing independence and shifts in relationships with parents and

peers. Overall rates of drug use peak and begin to subside

during these years. Most youths who abuse drugs in their

teens or early twenties desist as they mature into full

adults, but some do not and some initiate new abuse of

additional drugs: About 25 percent of smoking, 33 percent of marijuana use, and roughly 70 percent of cocaine

abuse begins after age 17. Personal, social, and demographic factors such as education, employment, and home

7
environment all appear to influence the patterns of abuse

in this period.

NIDA’s sharpened focus on emerging adults will support

development and testing of interventions to prevent initiation or escalation of drug abuse during this life transition

(RFA 04-013: “Prevention Research for the Transition to

Adulthood”). The research will draw on a broad array of

academic disciplines to generate and evaluate strategies of

intervening on factors ranging from interpersonal relationships— the negative influence of one intimate partner on

the drug use of the other, for example—to broader social

contexts, such as workplaces and college campuses.

The choices adolescents make have a profound impact.

NIDA’s intensified concentration on the interaction of

drugs and adolescent development will sharpen our understanding of those crucial choices, and will help us provide

adolescents with the information they need to choose

wisely. 

8
Web-Based Program Trains Practitioners To Add Prevention

Messages to Wellness Programs

Research Findings

Volume 19, Number 3 (September 2004)

In the last 20 years, drug abuse prevention strategies have increased dramatically in number and in scientific

sophistication. Prevention training 

programs have not kept pace, especially

in the area of equipping health professionals to deliver prevention education

to adults.

To make up this lag, ISA Associates of

Alexandria, Virginia, offers Prevention

Connection: Substance Abuse Prevention

Training for Health Promotion Practitioners. The Web-based training program was developed

and tested under a NIDA-supported Small Business

Innovation Research (SBIR) grant. It uses an interactive,

multimedia approach to train wellness professionals to

integrate substance abuse prevention materials and messages into health promotion programs across a range of

topics—from stress management to healthy eating, active

lifestyle, and parenting skills.

“Research shows that by integrating substance abuse messages into health promotion programs in the workplace

and community, we can reach a much larger audience and

reduce substance abuse,” says Dr. Royer Cook, principal

investigator for the project. “Unfortunately, many health

practitioners do not know enough about substance abuse

or how to incorporate relevant information into their programs. With Prevention Connection, any English-speaking

health practitioner with an Internet connection can learn

in just hours how to integrate substance abuse prevention

messages and materials into a wellness program.”

Prevention Connection emphasizes that health promotion

and health education practitioners can weave substance

abuse prevention information seamlessly into other health

promotion programs without losing the program’s impact

on the targeted health behavior. In addition to hands-on

exercises that allow practitioners to build their own program outlines, Prevention Connection helps wellness 

professionals understand the importance of integrating

substance abuse prevention with health promotion and

shows how substance abuse prevention makes good 

business sense.

Practitioners will appreciate Prevention Connection’s

indepth look at the leading substance abuse prevention

models and theories, descriptions of innovative workplace

prevention programs, and facts about drugs and their

effects. ISA tested the program with members of the

Worksite Health Promotion and Health Educator Groups

of the American College of Sports Medicine, who found 

it engaging and effective.

In the past two decades, ISA has completed eight NIDAfunded SBIR projects. Two more prevention projects are

in development: One targets prescription drug abuse, and

the other is a DVD-based program for young adults in 

the workplace.

9

Screen captures from the Prevention Connection Web site.
For More Information

The current annual licensing fee for an individual

Prevention Connection user is $495; group rates are available. To order Prevention Connection or to get more information about this and other employee-focused health

promotion programs offered by ISA Associates and the

Center for Workforce Health (www.centerforworkforcehealth.com), please contact Dr. Tracy McPherson

(tmcpherson@isagroup.com) or Dr. Royer Cook

(rcook@isagroup.com) at 703-739-0880. 

10
New Index Measures Self-Control, Predicts Drug Abuse

Vulnerability in Adolescent Boys

By Marion Torchia, NIDA NOTES Contributing Writer

Research Findings

Volume 19, Number 2 (July 2004)

Researchers at the University of

Pittsburgh’s Center for Education and

Drug Abuse Research have identified a

set of characteristics that appears to

predict a boy’s vulnerability to substance use disorder (SUD) in young

adulthood. Once validated for use with

the general population, this new construct, “neurobehavioral disinhibition,”

may help clinicians tailor drug abuse

prevention programs for children most

in need of support.

Under the direction of Dr. Ralph E.

Tarter, the researchers have conducted

comprehensive longitudinal studies to

understand how neurobehavioral disinhibition may relate to the genetic, biological, psychological, and environmental factors that are thought to predispose individual boys to SUD. They

have developed an index that links the

set of personality characteristics to a

quantitative scoring system. The index

appears to identify as early as age 10

children who are especially vulnerable

to drug problems in adolescence.

Neurobehavioral disinhibition comprises a cluster of emotional tendencies, behavioral symptoms,

and problems in cognitive function that indicate that a

child has not adequately developed psychological selfregulation, a capacity that depends on normal neurological development (see below, “Neurobehavioral

Disinhibition: A Closer Look”).

According to Dr. Tarter, the construct’s key strength is

its biological basis: Its elements closely relate to what is

known about the brain’s development. “Neurobehavioral

disinhibition points to deficiencies in those higher level

brain functions—self-control and deliberate, goal-directed

action—that we know are managed in the prefrontalcortex.”

According to Dr. Kevin Conway, director of the Program

on Antisocial Behaviors and Related Vulnerability in

NIDA’s Epidemiology Research Branch, Dr. Tarter’s

research shows that the construct actually works. He notes

that Dr. Tarter and his colleagues followed the same group

of children for more than a decade and

that “the children’s early scores for neurobehavioral disinhibition predicted

with amazing accuracy whether or not

they would develop SUD and how

severe their problems would be.” He

adds that 

“Dr. Tarter’s study takes earlier research

on vulnerability to drug abuse a step

forward and points to particular components of a person’s biological makeup

that may be at the root of the problem.”

Construct Developed, Tested

To develop their construct and its

numerical scoring system, Dr. Tarter’s

group tracked from childhood to

young adulthood 47 boys at high average risk and 65 boys at low average risk

of SUD based on their status as biological offspring of fathers with or without SUD as defined by the American

Psychiatric Association’s diagnostic criteria (DSM-III-R). The investigators

limited this particular study to boys

because the girls in their longitudinal

research program were enrolled later and had not been followed long enough to make valid predictions and match

the outcomes to them.

The neurobehavioral disinhibition construct was developed by assessing the children in the study using a series

of existing tools that measure dysregulated emotions,

behavioral undercontrol, and executive (higher order)

cognitive capacity. To measure emotion, for example,

the researchers used the “difficult” temperament index

from the Revised Dimensions of Temperament Survey.

They measured behavior “undercontrol” using two diagnostic tools, the Schedule for Affective Disorders and

Schizophrenia for School-Age Children, as rated by the

children’s mothers, and the Disruptive Behavior Disorders

Rating Scale, as measured by their teachers. A battery of

neurological tests measured cognitive processes that

depend on the prefrontal cortex.

11

Researchers hope that early identification

and treatment of neurobehavioral disinhibition can help at-risk children develop

self-control and avoid drug initiation

and abuse.
The next step, verifying the construct by a statistical technique called factor analysis, confirmed that the separate

components of neurobehavioral disinhibition—personality

style, behavior, and brain function—tend to occur together. This suggests that neurobehavioral disinhibition is driven by a single process involving prefrontal cortex functioning. Says Dr. Tarter, “We are looking at the integrity

of the brain by measuring its activities.”

Index Predicts SUD Vulnerability

To test the hypothesis that the neurobehavioral disinhibition score is correlated with expected risk of future SUD,

Dr. Tarter’s team compared the scores of the high-risk

boys in the study with those of the low-risk boys. The

boys at higher risk had significantly higher scores at ages

10 to 12 on several, though not all, of the component

indicators of neurobehavioral disinhibition. When the

boys were tested again at age 16, the higher risk boys had

scores consistent with neurobehavioral disinhibition on

every component indicator of the trait.

Moreover, the boys’ disinhibition scores at ages 10 to 12

predicted with nearly 70-percent accuracy whether they

would actually develop SUD by age 19. Even more strikingly, their disinhibition scores at age 16, combined with

their frequency of drug use in the previous 30 days, predicted with 85-percent accuracy their likelihood of developing SUD by age 19. In fact, the boys’ disinhibition

scores at age 16 were better predictors of SUD at 19 than

the frequency of their drug use at age 16. In addition,

their disinhibition scores were strongly predictive of the

general severity of their problems as measured by the

“overall problem density score” on the revised Drug Use

Screening Inventory. This score includes health, behavior,

school, family, and social adjustment problems.

The scores have both positive and negative predictive

value, according to Dr. Tarter’s research report. However,

some of the data indicate that a high disinhibition score

predicts that a boy will have SUD with a greater degree of

probability than a low score predicts that he will avoid the

disorder. The boys’ high scores at age 16 predicted future

SUD with 97-percent accuracy; on the other hand, low

scores at this age predicted with only 61-percent accuracy

that SUD would not develop.

12

Neurobehavioral Disinhibition: A Closer Look

The construct developed by Dr. Tarter and his colleagues includes many symptoms that characterize

attention-deficit/hyperactivity disorder, conduct disorder, and oppositional defiant disorder. But it reaches

beyond those diagnostic categories to describe emotional states and neurological capacities as well as their

behavioral manifestations.

Compared to his peers, a “disinhibited” child can be described as “difficult.” His (or her) moods are volatile,

and he often exhibits restlessness and an inability to persevere in a task. Poor self-management often 

reveals itself in risky, even reckless behavior. Neurological tests reveal a lack of certain capacities that 

originate in the part of the brain that manages higher level thinking. Three dimensions of his problem are

especially important:

• “Difficult” temperament. A disinhibited child is irritable and easily thrown off balance and has a harder

time than other children returning to a comfortable emotional state after a stressful or arousing experience. His emotions seem to be more intense than those of his peers. These characteristics commonly

provoke negative responses from adults and other children. If so, a vicious cycle can develop, and the

child’s reactions can become more extreme as time goes on. 

• Undercontrolled behavior. The disinhibited child’s behavior is chronically out of touch with the

demands of the situation. He or she has a hard time meeting a school’s learning requirements and

does not relate easily to either adults or peers. He may engage in “externalizing behavior” or “acting

out,” typically through disruptiveness, unprovoked aggression, defiance of authority, or delinquency. His

behavior is also marked by impulsivity and an inability to persist in pursuing his goals. 

• Deficiencies in complex brain functions. The prefrontal cortex in the human brain manages an individual’s purposeful activities. It is possible to measure a child’s ability to pay attention, to remain aware

of what is going on in the environment, and to complete a task or a coordinated sequence of actions.

For example, researchers can see whether a child can turn away from a signal and deliberately look in

the opposite direction when asked to do so. A disinhibited child will have trouble with this simple task,

which requires deliberate control over eye movement, a capacity that resides in the prefrontal cortex.
Value of Findings Cited

“From NIDA’s perspective, this research is a long-term

investment,” notes Dr. Conway. “Because it is a longitudinal study, Dr. Tarter and his colleagues have been able to

gather a broad range of information about the boys, so

that the effect of the multiple factors known to be related

to SUD can be traced over time.”

The next phase of the study will be especially interesting,

because the first group of boys will have entered young

adulthood, when SUD most often emerges. The researchers will continue to track the young men even as new participants join the study.

The findings should not be assumed to apply to all children, Dr. Tarter cautions. Before the trait can be considered universally valid and ready for use in working with

children, much larger studies will be needed involving the

general population, including both genders and diverse

ethnic and socioeconomic groups.

“It is important that our new knowledge be used to bring

about constructive change,” Dr. Tarter adds. “An index of

neurobehavioral disinhibition has potential value because

it offers an opportunity to monitor children’s development

and detect those children with significant deviations, who

may be at heightened risk of SUD. If teachers, counselors,

and parents can identify a child’s problems early, they can

structure environmental conditions to promote a healthy

outcome and avoid the path to SUD.”

Source

• Tarter, R.E., et al. Neurobehavioral disinhibition in

childhood predicts early age at onset of substance

use disorder. American Journal of Psychiatry 160(6):

1078–1085, 2003. 

13
School-Based Program Promotes Positive Behavior, Reduces

Risk Factors for Drug Use, Other Problems

By Susan Farrer, NIDA NOTES Contributing Writer 

Research Findings

Volume 18, Number 6 (February 2004)

Addressing a young student’s classroom antics may do

more than allow his teacher to get through a lesson.

Comprehensive, school-based programs can reduce young

children’s antisocial behavior while boosting their social

competency, academic performance, and commitment to

school, recent NIDA-funded research suggests. Such programs hold promise for reducing risk factors for drug use,

violence, school dropout, 

and other problem behaviors

during adolescence, the

researchers say.

Dr. Richard Catalano and colleagues at the University of

Washington in Seattle evaluated initial 18-month results of

the Raising Healthy Children

(RHC) program, designed to

reduce antisocial behaviors and

academic failure while promoting prosocial behaviors by

working closely with students

and their teachers and parents.

First implemented with NIDA funding in 1994, RHC

offers children in grades 1 through 12 age-appropriate services at school and at home. This unique long-term intervention addresses key factors that affect a child’s social

development at each age and either protect against or

increase the risk of drug use and other problems. The

original RHC program participants, who were 1st- and

2nd-graders in 1994, are now in 11th and 12th grades

and still participating in the program.

“Elementary school interventions are relatively rare but are

potentially very powerful if we can determine exactly what

the target risk and protective factors are and how to get to

them early,” notes Dr. Aria Crump of NIDA’s Prevention

Research Branch. “If we can intervene early—by addressing precursors to antisocial behaviors—then we’re getting

a head start on preventing problems.”

RHC is founded on the social development model, which

hypothesizes that elementary school children learn behavior patterns from teachers and peers at school as well as

their families, with peer influence increasing as children

age. The model also suggests that consistent patterns of

socialization with prosocial individuals create social bonds

that positively influence behavior. RHC strategies seek to

engender consistent, positive socialization and prosocial

development within children’s classrooms, peer groups,

and families.

Dr. Catalano, who with Dr. David Hawkins helped craft

the social development model, notes that it emerged from

a growing understanding of the

developmental etiology of substance use and other problem

behaviors. The model suggested that prevention interventions delivered to preadolescents might be effective.

“Longitudinal research has

shown that risk and protective

factors are present before adolescence and that we might

set kids on a different developmental path if we can change

these factors early in life,” 

Dr. Catalano explains.

“Building on this knowledge,

our research focuses on incorporating a developmental

approach into intervention efforts and addressing risk 

factors as they become salient.” 

The RHC program includes:

• Teacher workshops and booster sessions that support

classroom instruction—proactive classroom management, cooperative learning methods, and techniques

to improve children’s interpersonal and problem-solving skills, for example—to reduce academic failure

and early aggressive behaviors and enhance the protective factor of commitment to school. 

• Parent training and involvement strategies implemented by school-home coordinators through parenting

workshops and in-home family services to reduce

family management problems, family conflict, and

academic failure and enhance family bonding and

clear standards for behavior. 

• Summer camps and in-home services for students

identified by teachers or parents as being at risk

for academic failure or in need of enhanced social

competence. 

14
The RHC study included 938 1st- and 2nd-graders

enrolled in 10 suburban public schools in the Seattle area

in 1994. After the schools were paired by socioeconomic

status and attendance patterns, one school in each pair

was randomly assigned to the RHC group and the other

to a control group.

Data were collected from classroom teachers and parents

just before the study was launched and at the 6-month,

1-year, and 18-month marks. Additional data were gathered from students through simple surveys they completed

6 and 18 months after the study began. Teachers and parents rated children’s antisocial behavior, social competency,

academic performance, and commitment to school.

Students rated their own antisocial behavior and 

social competency.

For purposes of this study,

examples of antisocial

behavior include intentionally breaking things,

taking others’ things,

lying extensively, and initiating fights. Social competency includes, among

other behaviors, understanding others’ feelings,

cooperating with peers,

sharing things, and

accepting responsibility

for one’s actions.

Students appear to have

benefited from the RHC

program after only 18

months of participation.

The teachers’ reports

revealed that the intervention students were significantly more committed

to school and had higher

academic performance

than students in the control group. According to the

teachers, RHC students also displayed significantly more

social competency than did control students, with social

competency levels increasing for participants as they

decreased for those in the control group. The teachers’

reports also indicated that program students exhibited 

less antisocial behavior than their control group peers.

Further, the rate of new displays of antisocial behavior

declined in RHC students, whereas the rate in control 

students increased.

Parent-reported data confirmed that program students had

significantly higher levels of academic performance and

commitment to school than did the control group. However, neither the parent-reported nor student-reported data

showed significant differences between the two groups in

social competency and antisocial behavior after researchers

controlled for gender, low income, and baseline conditions.

The investigators say the lack of parent-teacher agreement

on items assessing children’s behavioral outcomes is not

surprising because this result is consistent with previous

research. “Generally, if you look at studies involving

teacher and parent reports, parents are less able to discriminate differences in behavior,” Dr. Catalano says.

The differences in teachers’ and parents’ reports on prosocial behavior may relate to several factors. First, parents

may not have as many opportunities as teachers do to

see their children interact in structured environments.

Second, parents may have less exposure to children’s social

behaviors, and their comparisons may be limited

to a small group of their

children’s friends.

The researchers suggest

that data collection issues

may account for childreported data not showing

significant differences

between program participants and nonparticipants

in social competency and

antisocial behavior. For

example, the children’s

young age precluded asking them a sufficient

number of questions to

measure all of the relevant

dimensions. In addition,

data were not collected

from the children before

the intervention began, 

so data provided by 

parents were used as 

baseline measures.

“The significant findings are that the intended targets for

intervention have been changed,” Dr. Catalano observes.

“On the risk side, it appears that we’ve reduced antisocial

behavior and academic failure. On the protective side, we

appear to have increased kids’ social competency and commitment to school.” 

The researchers observe that the study provides only preliminary results of the longitudinal RHC intervention,

and a NIDA-funded study of long-term RHC outcomes

in middle school and high school students is now underway. With its encouraging initial findings, this research

appears to support other evidence of the effectiveness of

social development interventions in young children. Dr.

Catalano notes that the RHC program replicates and

15

The Raising Healthy Children (RHC) program incorporates strategies

for teachers, parents, and students in grades 1-12. RHC seeks to develop

students’ prosocial behaviors, lessen antisocial behaviors, reduce academic

failure, and prevent adolescent problem behaviors, such as drug use and

violence.
extends the Seattle Social Development Research Project

(SSDP), but focuses on institutionalizing intervention

practices school-wide. Evaluation of the SSDP showed

short-term success in increasing academic performance

and reducing violent behavior. It also showed long-term

success in increasing academic performance and decreasing

substance use, drug-selling, and other problem behaviors.

“Because we’ve tried to find ways to enhance implementation of the practices and update the practices, we really

have a second generation of these studies,” Dr. Catalano

explains. “That makes it a stronger contribution than a

single study. The message is that developmental prevention can work and can be replicated.”

Sources

• Catalano, R.F., et al. Raising healthy children through

enhancing social development in elementary school:

Results after 1.5 years. Journal of School Psychology

41:143–164, 2003.

• Hawkins, J.D.; Catalano, R.F.; Kosterman, R.;

Abbott, R.; and Hill, K.G. Preventing adolescent

health-risk behaviors by strengthening protection during childhood. Archives of Pediatrics and Adolescent

Medicine 153(3):226–234, 1999. 

16
School Prevention Program Effective With Youths at High Risk for

Substance Use

By Robert Mathias, NIDA NOTES Staff Writer 

Research Findings

Volume 18, Number 5 (December 2003)

Science-based drug abuse prevention programs designed

for all students in the same middle school grade have significantly reduced early use of alcohol, tobacco, and other

substances. The benefits of these programs persist through

later grades, resulting in reductions in substance use

through high school. Originally developed and tested

among white students in suburban schools, such universal

prevention programs subsequently have been shown to

deter racially diverse, multiethnic students in urban

schools from initiating substance abuse. Now, a NIDAsupported study has shown that the prevention effects 

of one such program extend not only to students who 

are initially at low or moderate risk of early drug abuse,

but also to those at higher-than-average risk of initiating

substance abuse.

The study found that Life Skills Training (LST), a thoroughly tested, school-based, universal prevention program,

significantly reduced initiation of drug use among urban,

minority middle school students who were doing poorly

academically and had substance-abusing friends. Previous

research has linked these academic and social factors to

increased risk of subsequent substance abuse. Yet 1 year

after the LST program, these high-risk youths reported

lower rates of cigarette, alcohol, and inhalant use than a

comparable group of nonparticipating students. Moreover,

LST participants who reported using these substances

used them in lower amounts than nonparticipants.

“This study shows that a school-based universal prevention program, like LST, can have substantial prevention

effects for diverse youths, regardless of their level of risk

for substance abuse,” says Dr. Gilbert J. Botvin, who

developed the LST program and directs the Institute of

Prevention Research at Weill Medical College of Cornell

University in New York City. This finding counters the

prevailing notion that while universal programs are effective with broad groups of youths, more targeted and 

tailored interventions are needed for high-risk youths, 

Dr. Botvin says.

In the study, Drs. Botvin and Kenneth W. Griffin, also of

Cornell, tested the LST program’s effectiveness in a controlled trial with minority, mostly African-American and

Hispanic, inner-city students in 29 New York City schools.

Schools were randomly assigned to receive either the LST

program or the standard New York City substance abuse

education curriculum. Regular classroom teachers delivered

LST to participating 7th-graders in 15 sessions, each

approximately 45 minutes long, that inculcated anti-drug

norms and taught drug refusal, personal management, and

general social skills.

After determining that the LST program substantially

reduced early drug use among participants in the broad

17

Just in from the 2003 Monitoring the

Future study:

• Use of any illicit drug declined significantly 

for 8th- and 10th-graders, for the second year

in a row. 

• MDMA (Ecstasy) use is down significantly

among 8th-, 10th-, and 12th-graders. 

• Marijuana use declined significantly among

8th-graders. 

• Amphetamine and tranquilizer use are down

among 10th- and 12th-graders. 

• Steroid use declined among 10th-graders. 

• Heroin and crack use remained mostly stable,

with some decline among 10th-graders. 

• Lifetime cigarette use dropped in all three

grades, and past-month use was down among

12th-graders. 

• Alcohol use was unchanged in 2003, after

declining in 2002. 

• Increases in past-year inhalant use by 

8th-graders signal a potential problem. 

• Use of Vicodin, the illicit drug most used after

marijuana, and Oxycontin are high enough to

raise concern. 

MTF is an annual survey conducted by the

University of Michigan under a NIDA grant. Since

its launch in 1975, the study has surveyed high

school seniors; 8th- and 10th-graders were added

in 1991. The 2003 sample includes 48,467 public

and private school students from 392 schools.
student population, the researchers focused on a subgroup

of 426 students identified as being at higher-than-average

risk of initiating substance abuse. These students had Cs

or lower grades and friends who used both alcohol and

tobacco. The study also identified and tracked a control

group of 331 students with a similar high-risk profile.

Baseline assessments found no significant differences in

substance abuse rates between the two groups prior to the

intervention. Assessments conducted 1 year later found

lower rates of smoking, drinking, and inhalant and polydrug (multiple substance) abuse among participants than

were seen in students in the control group. For example,

22.1 percent of control students reported smoking in the

past month, compared with 15 percent of students who

participated in the LST program—almost a one-third

reduction in the rate of smoking. Similarly, compared

with controls, program participants had a 20.8 percent

lower rate of drinking, a 21.1 percent lower rate of marijuana abuse, a 90.5 percent lower rate of inhalant use,

and a 30.5 percent lower rate of polydrug abuse.

Students who participated in the LST program also had

lower scores than did control students in composite measures of the frequency and quantity of smoking, drinking,

and inhalant and polydrug abuse in the past month.

Significant program impact on marijuana abuse was not

found in composite measures or in rate of use 1 year after

the program ended.

Additional research is needed to determine whether the

initial prevention effects LST achieved in this study will

lead to later reductions in more severe levels of drug abuse

among high-risk youths, Dr. Botvin says. However, his

past research has shown that LST’s initial reductions in

experimental substance abuse in general populations of

students resulted in later reductions in pack-a-day cigarette smoking and polydrug use. A more recent study by

Dr. Botvin extended this finding of LST’s long-lasting

prevention effects to the incidence of binge drinking

(three or more drinks per episode) in later years among

inner-city minority youths. “The proportion of binge

drinkers was more than 50 percent lower in the intervention group than in the control group at both the 1-year

(8th grade) and 2-year followup assessments,” he notes.

“We are not saying that a universal prevention program

eliminates the need for more targeted prevention and

treatment programs down the line that meet the specific

needs of high-risk kids who already have more severe

drug and alcohol abuse problems,” Dr. Botvin cautions.

“Rather, we are saying that this body of research culminating in our study of high-risk students shows the utility of

a universal prevention approach for reducing initial substance use across the board from lower to higher risk white

and minority youths in suburban and inner-city schools.

By doing that, you’ll likely also reduce more severe levels

of later drug involvement.”

Sources 

• Botvin, G.J., et al. Preventing binge drinking during

early adolescence: One- and two-year follow-up of a

school-based preventive intervention. Psychology of

Addictive Behaviors 15(4):360–365, 2001.

• Griffin, K.W.; Botvin, G.J.; et al. Effectiveness of a

universal drug abuse prevention approach for youth

at high risk for substance use initiation. Preventive

Medicine 36(1):1–7, 2003. 

18

Prevention Program Reduces Substance

Abuse Rates Among High-Risk Students

Substance LST Participants Control Group

Cigarettes 15% 22.1%

Alcohol 16.4 20.7

Marijuana 11.2 14.2

Inhalants 0.2 2.1

Polydrug* 12.6 19.7

* Past-month use of multiple substances.

One year after participating in the Life Skills Training program,

urban minority students at high risk for substance use reported

lower rates of past-month substance use than peers who did not

participate in the program.
NIDA-Funded Research Drives Revision of Guide to

Prevention Programming

Research Findings

Volume 18, Number 4 (November 2003)

NIDA has released the second edition of its highly regarded Preventing Drug Use Among Children and Adolescents:

A Research-Based Guide for Parents, Educators, and Community Leaders in the fall of 2003. Like the first edition,

published in 1997, this booklet offers parents, educators,

and community leaders, as well as prevention practitioners, the latest findings from NIDA-funded prevention

research. Accompanying this edition is an In Brief companion piece for quick reference. The goal of both publications is clearly defined: to help communities apply the

findings from research-based prevention studies in

addressing drug use among children and adolescents.

In the last 5 years, NIDA’s prevention research program

has more than doubled in size and scope to address all

stages of youth development, a mix of audiences and settings, and the delivery of effective services at the community level. Research funded by NIDA and other Federal

research organizations—such as the National Institute of

Mental Health and the Centers for Disease Control and

Prevention—shows that early intervention can prevent

many adolescent risk behaviors.

NIDA-funded research has identified interventions that

can minimize or prevent risks for drug abuse and other

problem behaviors that can occur at every step along a

child’s development path. Working with families, schools,

and communities, scientists have found effective ways to

help people gain skills and learn strategies that can stop

problem behaviors before they occur and strengthen factors that protect youths from vulnerability to drug use.

Sixteen fundamental prevention principles, derived from

research on effective prevention programs, frame the

guide’s discussion. Using a question-and-answer format,

the booklet addresses

• key factors that place youths at risk for drug use, as

well as those that confer protection; 

• how to plan prevention programs tailored to community needs; and 

• core elements of effective programs, which should be

retained when adapting programs to match a community’s characteristics. 

Each chapter ends with a “Community Action Box” that

provides clear advice to parents, educators, and community leaders on how to apply that chapter’s information.

The revision also describes more than 20 prevention programs, tested and proven in controlled trials by researchers

throughout the Nation. Programs are described by the setting where they are implemented—the family, school, or

community—and by the audience they target—all youths

(universal programs), those at greater risk (selective programs),

and those already involved with drugs or other problem

behaviors (indicated programs). Some of the programs

described are tiered, targeting more than one audience.

Selected resources and references point to additional information to guide program planning and implementation.

To view additional NIDA publications and videos on drug

abuse prevention, visit www.drugabuse.gov/PubCat/

PubsIndex.html and select “Preventing Drug Abuse.”

19

Community Action Box

PARENTS can use information on risk and protection to help them develop positive preventive

actions (e.g., talking about family rules) before

problems occur.

EDUCATORS can strengthen learning and bonding

to school by intervening early to address aggressive behaviors and poor concentration—risks associated with later onset of drug use and related

problems.

COMMUNITY LEADERS can assess community

risk and protective factors associated with drug

problems to appropriately target prevention 

services.

Example of a Community Action Box, offering straightforward tips

on how parents, educators, and community leaders—the guide’s

primary readers—can apply the information found in each chapter.
NIDA National Prevention Research Initiative

Begins Broad Range of Studies

By Robert Mathias, NIDA NOTES Staff Writer 

Research Findings

Volume 18, Number 3 (October 2003)

NIDA’s National

Prevention Research

Initiative (NPRI) has

embarked on the next

generation of prevention

research. NIDA launched

the comprehensive initiative last year with three

requests for research that

could accelerate the development of new approaches to preventing drug

abuse and the adoption of

research-based programs

by communities in the

United States. Now, a

broad range of newly

funded studies has put

NPRI on a fast track to

achieving its goals. The

studies range from basic

behavioral research to

large-scale trials of proven prevention programs.

“We already have many interventions and prevention

strategies that we know work,” says Dr. Elizabeth

Robertson of NIDA’s Division of Epidemiology, Services

and Prevention Research. “Instead of continuing to focus

research on developing similar programs, NPRI is breaking new ground in all areas of prevention research. Basic

studies are looking at fundamental features that could be

incorporated into new prevention approaches.

Comprehensive research centers are tapping knowledge

from multiple scientific disciplines and applying them to

innovative prevention approaches. And large-scale field trials are studying the implementation of research-tested programs at multiple sites with diverse populations.”

Recently funded studies within each of three NPRI complementary components include the following efforts.

Basic Prevention Research

Studies in this arena seek to increase understanding of

fundamental aspects of human behavior. Research findings

will point to possible new prevention approaches or ways

to improve existing programs. For example, more

effective approaches are

needed for youths with a

strong need for stimulation that drives them to

pursue new and thrilling

experiences. These highsensation-seeking (HSS)

youths are known to be at

increased risk for substance abuse. One of the

first basic NPRI grants is

a communications study

assessing how basic differences in HSS youths’

motivation to seek reward

or avoid harm affect their

responses to drug abuse

prevention messages.

Findings from this small

lab study could aid the

design of more precisely targeted media messages to deter

drug use among youths with this personality trait.

Transdisciplinary Prevention Research Centers

(TPRCs)

TPRCs will focus the collaborative efforts of neuroscientists, behavioral and cognitive scientists, and drug abuse

prevention researchers on a specific research area that has

the potential for producing new approaches to drug abuse

prevention. Working as a team, TPRC scientists will synthesize and translate basic science discoveries in these areas

into new prevention approaches. They will also study the

underlying biological, psychological, and social processes

that account for the outcomes of successful research-based

programs and develop and test new prevention hypotheses

based on their findings.

Late last year, NIDA awarded $6.5 million to the

University of Southern California’s Keck School of

Medicine in Los Angeles to establish the first TPRC. This

Center is conducting basic research on memory, cognition, and peer group dynamics. For example, one study is

assessing how a prevention program that has shown it can

20

One recently funded study under the National Prevention Research

Initiative seeks to identify more effective prevention strategies for highsensation-seeking youths, whose strong need for stimulation places them

at heightened risk for substance abuse. The study is examining how this

population’s motivation to seek reward affects how they respond to drug

abuse prevention messages.
reduce drug use affects memory

associations and unconscious

thought processes that trigger drug

use. Better understanding of the

underlying behavioral states and

thought processes that influence

the program’s efficacy could be

applied to developing new prevention approaches or refining existing programs. NIDA is continuing

to solicit applications to establish

additional TPRCs.

Large-Scale Community Prevention Field Trials

Field trials bring together researchers, State and local agencies, and prevention practitioners to identify the processes

and mechanisms that contribute to the successful implementation and sustainability of science-based interventions in a range of settings. Late last year, NIDA awarded

more than $4.5 million in grants for four field trials. Each

trial is implementing a research-proven prevention intervention in a variety of communities. For example, a

University of Oregon study is integrating a family drug

abuse prevention program that focuses on improving parenting practices into the Special Supplemental Nutrition

Program for Women, Infants, and Children (WIC) in

rural, suburban, and urban communities. WIC is a

nationwide U.S. Department of Agriculture program that

provides nutritional and other assistance to low-income

women who are pregnant or have young children. The

study is examining how the characteristics of program participants and the settings in which the program is delivered affect program implementation and effectiveness.

Other field trials will

• Test whether school staffers in several different urban

settings can effectively deliver a delinquency and substance abuse prevention program targeting 5th- and

6th-graders who exhibit early signs of aggressive

behavior.

• Study how using onsite and remote training and technical assistance approaches affects the costs, accuracy,

and effectiveness of implementing a school-based program in middle schools. 

• Examine systemic barriers to successfully implementing a parent-focused program in government-sponsored health programs on a countrywide scale in 435

municipalities in Norway. This international collaboration should answer questions about how cultural

adaptation affects the program and whether government-sponsored health programs and municipalities

can train large numbers of social workers, psychologists, and health workers to deliver the program accurately and effectively. 

21

A University of Oregon field trial is using USDA’s Special Supplemental Nutrition Program for

Women, Infants, and Children (WIC) as a vehicle for delivering a family drug abuse prevention

program to rural, suburban, and urban communities.
Multiculturalism at Least as Effective as Cultural Specificity in

Test of Prevention Program

By Jill Schlabig Williams, NIDA NOTES Contributing Writer 

Research Findings

Volume 18, Number 3 (October 2003)

A multicultural version of a substance

use prevention program tested in middle schools in Phoenix, Arizona, proved

at least as effective as culturally targeted

versions, according to recent research

by Drs. Michael L. Hecht, Michelle

Miller-Day, and Flavio Marsiglia and

colleagues at Pennsylvania State

University and Arizona State

University. The NIDA-funded

researchers compared a multicultural

version of a drug prevention program—which included cultural values

from all of the groups participating in

the program—to two culture-specific

programs. The latter programs are

based on the hypothesis that messages

matched to the student’s culture are

more effective than messages that are

not culture-specific.

“This is good news for the future of

drug prevention in schools serving culturally diverse students,” says Dr.

Hecht. “It is very difficult logistically

to deliver culture-specific programs in

culturally diverse schools. Multicultural

programs are much easier to deliver,

and now we find that they’re also as

effective as culture-specific programs.”

Research has shown that students respond better to drug

prevention programs when they see their culture and

images of themselves represented in the prevention message. Moreover, minority youth respond favorably to programs that feature a teacher or characters from their own

ethnic group.

“We know that kids need to see something of their own

lives and cultures reflected in the programs,” Dr. Hecht

explains. “But we wanted to test the effectiveness of multicultural prevention programs and compare their effectiveness to selectively targeted or matched interventions.”

The prevention program, dubbed “keepin’ it R.E.A.L.”, is

a school-based intervention targeting substance use among

urban middle schoolers. Its goals are to reduce use of alcohol, cigarettes, and marijuana; promote antidrug norms

and attitudes; and develop effective

drug resistance decisionmaking and

communication skills. Through

NIDA funding, “keepin’ it R.E.A.L.”

was developed, tested, and evaluated

in 35 middle schools in Phoenix.

Designed to reflect aspects of the adolescents’ cultures and learning styles

in content and format, it includes

10 classroom lessons that promote

antidrug norms and teach substance

use resistance skills, life skills, risk

assessment, and decisionmaking skills.

The intervention was reinforced by a

public service announcement radio

and billboard campaign and by booster activities.

Three versions of the curriculum were

created and delivered: one based on

Mexican-American culture, one based

on African-American and EuropeanAmerican culture, and a multicultural

version using five lessons from each

of the other two versions. The large

proportion of Mexican or MexicanAmerican students (approximately 74

percent) in the study population contributed to the choice of MexicanAmerican culture for one curriculum version.

“In developing this program, we studied the process by

which kids resisted drugs and used a narrative approach

to teach these skills to other kids. The whole program

is from youth through youth for youth,” observes Dr.

Hecht. Stories of drug resistance were collected from adolescents in each ethnic group and used to write scripts for

videos that were then performed and videotaped by local

high school students. These 10 videotapes (5 for the

Mexican-American version, 5 for the African-American/

European-American version) form the core of the program.

They teach resistance skills through enactments of successful drug resistance in recognizable locales, by youths similar

to the students in age and ethnicity.

The lessons’ content is built on previous research on what

is effective in drug prevention. In addition, researchers

22
infused the curriculum with cultural

norms and values that are predominant within certain groups—for

example, the value of family to

Mexican Americans, respect to

African Americans, and individualism to European Americans.

Affirming these values can help students use familiar behaviors and

attitudes to resist drugs. The curriculum emphasizes family and cultural norms that discourage behaviors like drug use, equipping students with the skills to tap their

social support systems to effectively

resist drug offers.

“We don’t generalize about the cultures. We give them stories. We

show them scenarios that come

from their mouths. It’s always a specific situation, with no moralizing,”

says Dr. Hecht.

In the fall of 1998, 25 Phoenix middle schools were randomly assigned

to one of the three versions of the

curriculum, and 10 schools were

assigned to the control condition.

Schools in the control condition

received other drug prevention programs already planned

for those schools, including a statewide antitobacco campaign. The research team administered a preintervention

survey to all participants and then implemented the curriculum in 7th-grade classes in the 25 treatment schools.

Followup surveys were conducted 2 months, 8 months,

and 14 months after curriculum implementation. Surveys

included questions on demographics; recent alcohol, cigarette, and marijuana use; use of resistance strategies

learned in the program; antidrug norms; and intentions to

accept substances. The final sample included 6,035 students, of whom 55 percent were Mexican American, 17

percent were non-Hispanic white, 9 percent were African

American, and 19 percent were of other Latino or multiethnic Latino origin.

The results showed that the interventions were significantly more effective than the control condition, with statistically significant effects on the use of gateway drugs (alcohol, tobacco, and marijuana) and on norms, attitudes, and

use of resistance strategies. Students participating in any of

the three test versions reported better behavioral and psychosocial outcomes related to substance use than did the

control students. Although use of alcohol, cigarettes, and

marijuana increased over time for both sets of students,

the rate of increase was significantly less for students who

participated in the intervention. Those students also

reported adopting more resistance strategies.

When researchers compared the three versions of the curriculum against the control group, they found that the

Mexican-American and multicultural versions of the curriculum had far more significant effects over the course of

the study. Students who participated in the multicultural

curriculum had, on average, the smallest increases in use

of alcohol and marijuana from pretest to final posttest,

and the second-smallest increase in use of cigarettes. 

The Mexican-American and multicultural versions of 

the program had positive effects on several of the psychosocial outcomes studied, including intent to refuse

substance offers and antidrug attitudes for themselves 

and their friends.

To determine if matching program content to a student’s

ethnicity enhanced program outcomes, the researchers

used the students’ ethnic self-labeling to categorize them

as matched to the curriculum they received, mismatched,

or mixed (i.e., various ethnicities receiving the multicultural program). Very few significant differences in program effectiveness emerged; therefore, the researchers

found little support for the cultural matching hypothesis.

23

Multicultural Intervention Had Greatest Impact on 

Substance Use Initiation

The multicultural version of the intervention program “keepin’ it R.E.A.L.” had the greatest

positive impact on initial substance use over the course of the study, compared to controls and

to the culture-specific versions. Students who participated in the multicultural version of the

program had the smallest increase in alcohol or marijuana use and the second smallest increase

in cigarette use from the initial preintervention survey to the final postintervention survey, 14

months after implementation of the curriculum.
“We created an intervention that worked, and we found

that the multicultural version worked as well as—or better

than—the culture-specific versions,” says Dr. Hecht. “We

found that it is not necessary to ethnically segregate students into narrowly tailored programs to achieve effectiveness. Rather, it is critical to incorporate a representative

level of relevant cultural elements.”

The Center for Substance Abuse Prevention has recently

added the “keepin’ it R.E.A.L.” curriculum to its National

Registry for Effective Prevention Programs, recognizing it

as an effective program and making it available to middle

schools across the country for implementation. In the

future, Dr. Hecht and his colleagues plan to study the

effectiveness of offering intervention programs to students

as early as 5th grade. They also plan to look at the process

of acculturation, examining how Mexican-American youth

make the transition to a new culture and language, how

that process puts them at risk for increased drug use, and

how to combat those risks.

“This is one of the first studies to compare multicultural

and culturally specific substance abuse prevention approaches,” says Dr. Aria Davis Crump of NIDA’s Division of

Epidemiology, Services and Prevention Research. “This

research highlights the importance of continuing efforts

to better understand how to effectively provide prevention

services in a culturally diverse society.”

Source

• Hecht, M.L., et al. Cultural grounding in substance

use prevention: An evaluation of the Drug Resistance

Strategies intervention. Prevention Science, in press.

24

A Name to Remember: 

“keepin’ it R.E.A.L.”

Preliminary research identified four strategies 

adolescents use to successfully resist offers of 

substance abuse:

• Refuse by verbalizing simple “no” statements. 

• Explain by elaborating reasons for refusing. 

• Avoid situations known to involve alcohol,

tobacco, or other drugs. 

• Leave the environment once substance use

enters the picture. 

These strategies constitute the acronym “R.E.A.L.,”

which students later translated into “keepin’ it

R.E.A.L.” Each of the four videos focused on one

of these strategies, and an introductory video was

added to kick off the program.
Relationships Matter: Impact of Parental, Peer Factors on

Teen, Young Adult Substance Abuse

By Arnold Mann, NIDA NOTES Contributing Writer 

Research Findings

Volume 18, Number 2 (August 2003)

The influence of family and peers

on adolescent substance abuse has

been well documented in the scientific literature. Generally, positive

family influences, such as family

bonding and consistent rules,

appear to reduce the risk of tobacco,

marijuana, and other drug abuse

among teens, while negative family

influences tend to increase risk. The

same is true of positive and negative

peer factors. Little research, however, has been conducted to see how

parental and peer factors interact to

influence adolescents’ initiation to

and young adults’ use of drugs.

Two new NIDA-funded studies—

one looking at initiation of substance use, the other at continued

substance abuse—show that some

aspects of family and peer influences

remain potent from early initiation

into young adulthood and across

socioeconomic, ethnic, and gender

lines. Both studies yielded surprises

and implications for intervention.

For example, the first study found that although family

and peer factors had similar effects on males and females,

family monitoring and rules had a stronger protective

effect for males than females. The second study found that

for either gender, peer influence was not mediated by the

quality of the relationship, except for female peer influence on young adult marijuana use.

Impact of Family on Teens’ Initiation to Drugs

University of Washington researchers recruited 808 5thgraders from 18 Seattle elementary schools in high-crime

areas and followed them from ages 12 to 21 to see how

peer, family, and sociodemographic factors interacted to

influence drug initiation. 

As part of an ongoing NIDA study directed by Dr. J.

David Hawkins, data from this group were gathered annually through age 16 and again at 18 and 21. The sample

included a high proportion of low-income families, “but

not all children came from homes in high-risk neighborhoods,” says Dr. Karl Hill, one of the study’s authors. Of

concern were the extent of bonding to family, family

involvement (time spent interacting with parents), family

conflict resolution and parenting practices (monitoring,

rules, and consistent discipline), peers’ prosocial and 

antisocial activities, and measures of use for tobacco, 

marijuana, cocaine, amphetamines, tranquilizers, sedatives,

and psychedelics. 

Initiation of illicit drug use for the entire study group was

4.6 percent by age 12, 8.4 percent by age 13, 12.6 percent

by age 18, and 40.5 percent by age 21. By age 21, 45.4

percent of male participants had initiated illicit drug use,

as had 35.5 percent of females. Native Americans had the

highest rate of initiation, at 55.9 percent, compared to

53.6 percent of European Americans, 33.3 percent of

African Americans, and 14.6 percent of Asian Americans.

25

Family Bonding and Peer Antisocial Activity Impact

Drug Initiation Among Adolescents

Low levels of family bonding and high levels of peer antisocial activity were consistently associated with higher prevalence of illicit drug initiation among youths ages 12 to 21 compared

with prevalence seen when high levels of family bonding and low levels of peer antisocial activity were present. By age 21, however, a high level of family bonding had far less impact than

in earlier years on adolescent drug initiation.
All of the measured family factors

were influential, with the terms low

level referring to families in the lowest 10 percent for a specific factor

and high level referring to those in

the highest 10 percent. Higher levels of family monitoring and rules

were associated with a “significantly” lower risk of illicit drug initiation, according to Dr. Hill. For

example, youths with low levels of

family monitoring and rules at age

18 were twice as likely (14 percent

versus 7 percent) to initiate illicit

drugs as those with high family

monitoring. The same was true for

a higher level of moderate and consistent family discipline—youths

with low consistent family discipline

were over twice as likely (15 percent

versus 6 percent) at age 18 to initiate illicit drugs as those with high

consistent family discipline.

Family bonding was particularly

influential before the age of 18—

youths with low family bonding at

age 15 were three times more likely (9 percent versus 3

percent) to initiate illicit drugs than those with high family bonding. Higher levels of family conflict were associated with a higher risk of initiation. For example, youths

with high family conflict at age 18 were over twice as likely (15 percent versus 6 percent) to initiate illicit drugs as

those with low family conflict. High levels of peer antisocial activity, especially after age 15, found youths at age 18

nearly four times as likely (19 percent versus 5 percent) to

initiate illicit drugs as those with low antisocial peer influence (in the bottom 10 percent).

Family monitoring and rules seemed to reduce the risk of

initiation primarily by affecting the child’s choice of peer

groups. “Some family factors operate through peers and

some are independent of peer groups,” Dr. Hill explains.

“Kids with low bonding to parents are more likely to get

involved with narcotics and stimulants, even if they don’t

hang out with bad peers. So you end up with this set of

independent risks with high family conflict, low bonding,

and bad peer involvement. All these things stack the deck

toward initiation of serious drug use.

“In general, family and peer factors had similar effects on

boys and girls,” Dr. Hill observes. “Only family monitoring and rules had a stronger protective effect for males

than for females.” Family monitoring and bonding were

more predictive for European Americans than for African

Americans. Otherwise, says Dr. Hill, “family and peer factors affecting illicit drug initiation were similar across gender and ethnic groups.”

The message is clear: Family factors matter. “The impact of

only one factor—family bonding—begins to decline after

age 18,” Dr. Hill says. Peer factors also matter. Having antisocial peers, especially after age 15, increases the risk of drug

initiation. “Both sets of influences contribute,” he says,

“even after controlling for sociodemographic background

and prior alcohol, tobacco, and marijuana initiation.”

In terms of intervention, “family and peer factors should

be important targets for preventive efforts,” Dr. Hill says.

The effort should start early and continue into the twenties, emphasizing family bonding early and family monitoring, rules, and reduction of conflict throughout.

“Programs that address these family and peer factors

should work relatively well across gender and ethnic

groups,” he concludes.

Influence of Peers on Young Adults’ Substance Abuse

Another NIDA-funded study took a slightly different

path, looking at peer influence on young adults. As part of

a long-range study led by Dr. Hyman Hops of the Oregon

Research Institute in Eugene, Oregon, the researchers

gathered data from 294 participants ages 19 to 25. Each

participant brought one same-sex and one opposite-sex

peer into the study; those who were married brought their

marital partner as their opposite-sex peer. Data gathered

annually for 3 years included the quality of these relationships, the extent of any substance abuse, and the problems

associated with drug use.

26

Quality of Female Peer Relationship Impacts

Young Adult Marijuana Use

Each participant brought one same-sex and one opposite-sex peer into this study; participants

who were married brought their spouse as their opposite-sex peer. The quality of the relationship with a female peer was a factor in young adults’ marijuana use; with young adults’ use

of other substances, however, the quality of the peer relationship was not a factor.
At the beginning of the study, 30 percent of the 294 participants had smoked cigarettes, 29 percent had smoked

marijuana in the previous month, 10 percent had used

other illicit drugs, and 41 percent reported problems associated with drug use in the previous 12 months. Thirtynine percent had not used any drugs in the period specified. Men who smoked marijuana did so, on average,

more often than female marijuana smokers did—an average of 5.5 times per month versus women’s average of 2.7

times a month. “Other differences between genders were

not significant,” says Dr. Judy Andrews, lead author of the

Oregon team. “Correlations between various substances

were moderate.”

Use of drugs by male peers positively influenced subsequent

use by both men and women. “I expected females, in general, to be more influenced by males than by females,” Dr.

Andrews says, “and we found that to be true only in cases

where the user reported problems associated with drug use.

For example, friends of both genders also influenced both

males’ and females’ subsequent cigarette smoking.”

Another surprise emerged in the effect of good versus bad

peer relationships. In general, the quality of the relationship with the friend did not matter when it came to substance use. “We expected that peer influence would be

mediated by the quality of that relationship,” explains Dr.

Andrews. “If you don’t like somebody, why would you

emulate him or her? But we found this effect only with

marijuana use when the peer was female. Good female

friends influenced the marijuana use of both males 

and females. But if the good friend was male, he did 

not influence the marijuana use of either his male or

female friend.”

Again, the overall message is clear: Young adults are influenced by their friends. “It’s an important finding,” observes

Dr. Andrews. “Interventions with substance-abusing young

adults should not only be with individuals, but with their

peers as well.”

“We are continuing to see family and peer effects into early

adulthood,” says Dr. Kathleen Etz of NIDA’s Division of

Epidemiology, Services and Prevention Research. “People

assume that families become less important as kids move

out of the house, and this does not appear to be the case.

“Many of our interventions target adolescents and very

few target young adults. Given that in the Oregon

Research Institute study marijuana use was initiated after

high school, it’s clear that we have to look more carefully

at interventions for young adulthood.” 

Sources

• Andrews, J.A.; Tildesley, E.; Hops, H.; and Li, F.

The influence of peers on young adult substance use.

Health Psychology 21(4):349–357, 2002.

• Guo, J.; Hill, K.G.; et al. A developmental analysis of

sociodemographic, family, and peer effects on adolescent illicit drug initiation. Journal of the Academy of

Child and Adolescent Psychiatry 41(7):838–845, 2002.

27
Few Middle Schools Use Proven Prevention Programs

By Patrick Zickler, NIDA NOTES Staff Writer 

Research Findings

Volume 17, Number 6 (March 2003)

Since 1994, U.S. schools have been

able to use Federal funds to provide

education programs designed to

prevent drug abuse. Under amendments to the Safe and Drug-Free

Schools and Communities Act

(SDFSCA) in 1998, however, the

schools receiving Federal grants for

drug abuse prevention were required

to use an evidence-based curriculum. There are several such curricula, incorporating elements proven to

be effective in reducing teen drug

use: information about the effects of

illicit drugs, alcohol, and nicotine as

well as information about social

influences, refusal skills, assertiveness, and decisionmaking.

In 1999, shortly after the SDFSCA

amendments took effect, NIDAsupported researchers found only

one in four middle schools that

offer drug abuse prevention programs met standards set in the

Principles of Effectiveness. Dr. Christopher Ringwalt of

the Pacific Institute for Research and Evaluation in Chapel

Hill, North Carolina, Dr. Susan Ennett of the University

of North Carolina, and colleagues surveyed more than

1,900 U.S. middle schools to assess the use of evidencebased programs. They found, Dr. Ringwalt says, that relatively few schools appear to consider research results when

selecting programs. “Only about a third of the Nation’s

public schools and one-eighth of private schools are using

substance prevention curricula for which there is evidence

of effectiveness,” he says.

The 1,656 public and 249 private schools surveyed all

include some or all middle school grades (5 through 8).

Respondents identified, from a list of 51 prevention programs, which program their school used. Programs on the

list included 10 research-based programs identified as

effective in reviews published by NIDA, the Center for

Substance Abuse Prevention (CSAP), the Centers for

Disease Control and Prevention (CDC), the Safe and

Drug Free Schools Program of the U.S. Department of

Education (SDFSP), or Drug Strategies, Inc. (DSI). The

researchers also asked instructors to respond to questions

about how the program was taught in the classroom.

Project Alert—identified as effective by CSAP, DSI, and

SDFSP—was used by 19 percent of public and 6 percent

of private schools. Life Skills Training—identified as effective by NIDA, CSAP, CDC, DSI, and SDFSP—was used

by 12 percent of public and 3 percent of private schools.

The most prevalent curriculum—used by 53 percent of

public and 54 percent of private schools—is DARE (Drug

Abuse Resistance Education), which has been extensively

evaluated and found to be ineffective, Dr. Ringwalt observes.

Responses to questions about how the programs are

taught suggest that only one school in five uses them to

maximum advantage, according to Dr. Ennett. “To be

successful, prevention programs need more than effective

content,” Dr. Ennett explains. “They also must be delivered effectively, by instructors who involve students in

role-playing and other interactive, participatory activities. 

28

Most Middle School Prevention Programs Don’t Combine

Effective Content and Delivery

Of 1,795 instructors surveyed, only 1 in 7 (14 percent) provided programs that combined

effective content with effective delivery in some or most sessions as defined in the Safe and

Drug-Free Schools and Communities Act’s “Principles of Effectiveness.”

Criterion Percentage of Programs/Instructors

Meeting the Criterion

Effective Use of Content

Some or most sessions include knowledge about 62%

drugs and alcohol, refusal skills, and generic skills 

such as decisionmaking, communication, assertiveness, 

and social skills.

Effective Delivery 

Some or most sessions involve interactive methods 17

such as role-playing.

Content and Delivery

Combine effective content with effective delivery. 14
Unfortunately, we found that only about 21 percent of

instructors used effective, interactive delivery.”

In all, the researchers summarize, only one school in

seven offers prevention programs that incorporate elements proven to be effective and delivers the content in

the most effective way.

These findings paint a discouraging picture, observes

Dr. Elizabeth Robertson of NIDA’s Prevention Research

Branch, but it may be improving. “Dr. Ennett and Dr.

Ringwalt gathered their data only a year or so after the

Department of Education issued the Principles of Effectiveness that could help schools select the most effective

prevention programs. It’s likely that more schools are now

using materials that meet the guidelines for demonstrated

effectiveness,” Dr. Robertson says. “And instructors working

with effective programs are likely to deliver the program

content effectively. When both content and delivery are

combined day-to-day in the classroom, we should begin to

see, in studies such as the annual Monitoring the Future

survey, major reductions in substance abuse among schoolage youth.”

Sources

• Ennett, S.T., et al. A comparison of current practice

in school-based substance abuse prevention programs

with meta-analysis findings. Prevention Science, in

press.

• Ringwalt, C., et al. The prevalence of effective substance abuse prevention curricula in U.S. middle

schools. Prevention Science 2(4):257–265, 2002. 

29
Grouping High-Risk Youths for Prevention May Harm

More Than Help

By Jill Schlabig Williams, NIDA NOTES Contributing Writer 

Research Findings

Volume 17, Number 5 (January 2003)

Grouping high-risk youths in early adolescence may inadvertently reinforce problem behavior, according to a

NIDA-funded study by researchers Dr. Thomas Dishion

and his colleagues at the University of Oregon Child and

Family Center. They found that 11- to 14-year-olds at

high risk for drug abuse and increasingly serious delinquency who were grouped together for a 12-week program

designed to reduce problem behavior actually increased

their levels of self-reported smoking and teacher-reported

delinquency over 3 years. These youths exhibited significantly worse behaviors than similarly at-risk youths who

were given prevention materials to study by themselves

individually or received no intervention at all.

These findings raise important questions about the common practice of grouping high-risk, aggressive, or antisocial adolescents together in interventions. The results are

consistent with a number of studies elucidating negative

peer dynamics within high-risk youth groups.

“The failure of some very sophisticated interventions to

improve behavior has been a mystery in the field for many

years,” says Dr. Elizabeth Robertson, chief of NIDA’s

Prevention Research Branch. “Now, this research from Dr.

Dishion offers some clues to help us understand what’s

going on.”

The youths originally took part in a 12-week cognitivebehavioral intervention called the Adolescent Transitions

Program (ATP), designed by Dr. Dishion and his colleagues. ATP aimed to improve the behavior of young

adolescents identified by their parents as having problems

in at least four of the following risk areas: closeness to

parents, emotional adjustment, academic engagement,

involvement in positive activities, experience-seeking

behaviors, substance use, having friends who use substances, or family substance use history. The study was

designed to compare the effectiveness of intervention

approaches focusing on parental influence and on 

peer influence.

A total of 158 at-risk youths (83 boys and 75 girls) aged

11 to 14, enrolled in grades 6 through 8, were randomly

assigned to a parent-only group intervention, a peer-only

group, a parent-and-peer group, or control conditions that

involved no group meetings. The control group received

reading materials and videotapes or else no intervention

at all.

All of the group interventions used discussion and roleplay to build skills in managing emotions, setting limits,

building relationships, and refusing drug offers. Parentfamily management practices and communication skills

were the focus of the parent-only intervention. Researchers

followed study participants at 1, 2, and 3 years postintervention, looking at teacher reports of delinquency and the

participants’ self-reports of frequency of tobacco use—

confirmed by assessment of expired carbon monoxide

levels.

At the end of 12 weeks, researchers found that all three

intervention groups improved parent-child interactions

30

Problem Behavior Increases Following

Peer Group Intervention

Teacher reports of problem behavior among the 11- to 14-year-olds

in the prevention study showed that adverse effects of the peer-group

interventions extended to 3 years after the end of the study period.

A score of 0 would indicate a student is seen as never engaging in

problem behavior; the maximum in this study, a score of 12, indicates several problem behaviors reported.
and skills acquisition. However, at 1-year followup, participants in the peer-only and the parent-and-peer intervention groups had increased rates of self-reported smoking

and teacher-reported problem behavior. After 3 years, adolescents grouped with peers for the 12-week program

reported twice as much tobacco use as those who were not

grouped with peers. In addition, teacher reports of delinquency were 75 percent higher for study participants

grouped with peers than for all other groups. Additional

analysis revealed that youth with initially low levels 

of problem behavior showed the greatest increase in 

problem behaviors.

“For the ATP program, we hypothesized the opposite of

what we found,” says Dr. Dishion. “We wanted to use

the reinforcing power of peers to promote abstinence and

improve behavior. Instead, at 1-year followup we found

that kids grouped with peers were actually exhibiting more

problem behaviors than those who had not been grouped

with peers.”

Dr. Dishion describes the method by which peers negatively influence one another as “deviancy training”: for

example, rule-breaking discussions about drug use receive

positive responses from peers, further encouraging such

behavior and more discussions. In a previous study of adolescents interacting one on one, Dr. Dishion had found

that antisocial peers react positively to rule-breaking discussions, while nondeviant peers react positively to normative discussions. He hypothesizes that this process may

also occur among youths grouped for treatment, thwarting

the assumed benefits of the group setting.

These interactions are very subtle and can occur even in

situations designed to promote positive behavior. In the

ATP trial, for example, all sessions were videotaped. Later

analysis of the tapes revealed that interactions before and

after sessions and during breaks actually negated positive

interactions that went on during the intervention.

“This research is most relevant for the youngest adolescents—from junior high to early high school. We’re

hypothesizing that negative peer influences are most dangerous at the outset of drug use,” he says.

A great deal more research is needed to study the unintended effects of interventions. Not all interventions with

peer groups exhibiting problem behavior have had adverse

effects. “We’re working to understand which situations are

the most problematic. We don’t want to make a blanket

statement that aggregating kids will always have a negative

effect,” he says. “Additional data also exist,” Dr. Dishion

notes, “that indicate that peer interventions may result in

beneficial effects, especially when the groups include

prosocial youth.”

Dr. Dishion says also that the more effective interventions

for adolescents target parenting practices. “Adult involvement is needed to prevent escalating cycles of risk in young

people. Without adult involvement, youngsters are left vulnerable to peer effects,” he says.

NIDA’s Dr. Robertson agrees that finding better ways to

help at-risk children and adolescents is of utmost importance. “A small percentage of troubled kids grow into

those adults with the majority of social and health problems, including substance abuse, criminality, and sexually

transmitted diseases. It is worthwhile to find better ways

to identify at-risk kids and intervene with them, their

families, and their schools earlier in their lives—as early

as preschool.”

Sources

• Dishion, T.J.; McCord, J.; and Poulin, F. When interventions harm: Peer groups and problem behavior.

American Psychologist 54(9):755–764, 1999.

• Poulin, F.; Dishion, T.J.; and Burraston, B. 3-year

iatrogenic effects associated with aggregating high-risk

adolescents in cognitive-behavioral preventive interventions. Applied Development Science 5(4):214–224,

2001. 

31
Social Environment Appears Linked to Biological Changes in

Dopamine System, May Influence Vulnerability to Cocaine Addiction

By Kimberly R. Martin, NIDA NOTES Contributing Writer 

Research Findings

Volume 17, Number 5 (January 2003)

Cocaine is a highly addictive drug; however, little is

known about the factors that make some individuals more

vulnerable to it than others. Recently, NIDA-supported

researchers at Wake Forest School of Medicine in

Winston-Salem, North Carolina, have provided potential

insight as to why some drug abusers have an increased 

susceptibility to cocaine addiction. They have found a link

in monkeys between environmental conditions, the brain

chemical dopamine, and the addictive qualities of cocaine.

In the study, transferring the animals from individual 

to social housing produced biological changes in some

animals that decreased their response to cocaine.

Previous studies have indicated that certain environmental

conditions—such as living in an enriched environment

with access to more resources or reduced stress—may

reduce animals’ self-administration of drugs, particularly

cocaine. Animal studies also have suggested that environmental conditions may affect the activity of dopamine.

Specifically, these studies have indicated that animals’

housing conditions and social rank can affect dopamine’s

ability to bind to dopamine D2 receptors and thereby initiate the cellular processes that produce feelings of pleasure

and reward. Taken together, these findings inspired the

Wake Forest researchers to look for a three-way link

between environment, dopamine D2 receptor function,

and drug self-administration.

The researchers studied 20 macaque monkeys that were

first housed individually and then assigned to social

groups of 4 monkeys per housing group. Social hierarchies

were allowed to develop in each group, and social rank

was determined by observations of aggressive and submissive behavior. “Placement of the monkeys in social groups

is modeling two extremes—socially derived stress for the

most subordinate monkeys and environmental enrichment

for the dominant monkeys,” said Dr. Michael Nader, who

led the study. “Although these variables have been studied

in other animal models, in our model the stressors and

environmental variables were not artificially produced in

the lab. The model also allows us to study issues related 

to cocaine-induced changes in social behavior and the

interactions of those changes with the reinforcing effects

of cocaine.”

Positron emission tomography (PET) was used to measure

the amount and availability of dopamine D2 receptors

while the monkeys were individually housed and 3 months

after their placement into social groups. After the second

PET scan, monkeys were trained to self-administer cocaine

by pressing a lever. They were allowed access to cocaine

during daily sessions; the rate of cocaine self-administration

was determined by the number of times the lever was

pressed.

The second PET scan revealed that the monkeys that had

become dominant now had 20 percent more dopamine

receptor function compared to when they were housed

alone. In the subordinate monkeys, dopamine receptor

function was unchanged. Although dominant monkeys

did not avoid cocaine completely, they had significantly

lower intakes of cocaine than subordinate monkeys.

32

Brain Images of Monkeys Housed

Individually and After Transfer to

Social Housing

In these PET scans, lighter colors represent increases in markers of

dopamine D2 function. Greater levels of D2 markers in socially

housed, dominant monkeys—attributed to their living in an

enriched environment—suggest that positive changes in one’s

environment can result in a biological protection from cocaine

addiction.
“The increase in markers of dopamine D2 receptor function among dominant monkeys may be the result of an

increase in the number of dopamine D2 receptors, a

decrease in the amount of circulating dopamine competing for the receptors, or both as a consequence of becoming dominant,” says Dr. Nader. “This suggests that, regardless of an individual’s past, positive changes in the

environment may result in a biological protection from

the effects of cocaine. In other words, living in an enriched environment may enhance dopamine function and

thus cause the pleasurable effects associated with cocaine

use to be diminished.”

The Wake Forest team’s findings in monkeys have implications for understanding and possibly reducing drug abuse

vulnerability in people. In people as in monkeys, drugs’

effects on dopamine levels and function are a key to the

motivation for abuse. There is evidence that individuals

with low levels of dopamine D2 receptors have higher risk

for abusing drugs. In these individuals, reduced dopamine

function may produce less bountiful feelings of pleasure

and reward from natural activities, making drug-induced

euphoria more compelling. The new results suggest that it

may be possible to identify environmental improvements

that enhance individuals’ dopamine D2 receptor function

and thereby lower their risk for drug abuse.

“Dr. Nader’s research shows that environmental experiences

can increase dopamine D2 receptor levels, which in turn

are associated with a decreased vulnerability to cocaine

self-administration,” says Dr. Cora Lee Wetherington of

NIDA’s Division of Neuroscience and Behavioral Research.

“This work, along with previous research regarding the role

of dopamine D2 receptors in drug abuse, points to the

need for additional research to identify both environmental

factors that promote low dopamine D2 receptor levels and

the associated vulnerability to cocaine’s reinforcing effects as

well as environmental factors that give rise to high levels of

dopamine D2 receptors that confer resistance to cocaine’s

reinforcing effects. Such research could point to risk and

protective factors that could be translated into better prevention and treatment interventions.”

Source

• Morgan, D., et al. Social dominance in monkeys:

Dopamine D2 receptors and cocaine self-administration. Nature Neuroscience 5(2):169–174, 2002. 

33
Youths’ Opportunities To Experiment Influence Later Use of

Illegal Drugs

By Kimberly R. Martin, NIDA NOTES Contributing Writer 

Research Findings

Volume 17, Number 5 (January 2003)

NIDA-supported researchers have reported new epidemiological evidence about the associations linking earlier alcohol or tobacco use with later use of marijuana, and the

link from earlier marijuana use to later use of other illegal

drugs such as cocaine and hallucinogens. This study builds

on the many prior NIDA-supported studies of the “gateway” theory of youthful drug involvement: Once use of

tobacco or alcohol begins, there is greater likelihood of

marijuana use, and once marijuana use begins, there is

greater likelihood of other illegal drug use.

“This research increases our understanding of the complex

relationship between the different stages of drug use and

raises concerns about factors that promote the transition

from opportunities to initiate drug use to patterned use,”

says Dr. Kathleen Etz of NIDA’s Division of

Epidemiology, Services and

Prevention Research. “We

know that earlier drug use is

associated with later, more

advanced use; however, this

research identifies a previously

overlooked aspect of this transition, opportunities to use.”

Using annual data from the

1991 through 1994 National

Household Survey on Drug

Abuse (NHSDA), the research

team, led by Dr. James C.

Anthony from Johns Hopkins

University Bloomberg School of Public Health in

Baltimore, analyzed the responses of 26,015 individuals

aged 12 to 18 who answered questions regarding marijuana use and the responses of 44,624 individuals aged 12

to 25 who answered questions regarding cocaine use.

The research focused on a concept called “drug exposure

opportunities.” This concept takes into account that some

young people actively seek out opportunities to try marijuana or cocaine, whereas others are more passive recipients of drug exposure opportunities.

The researchers found that alcohol and tobacco users were

more likely than nonusers to have an opportunity to try

marijuana and were also more likely to try the drug when

the opportunity arose. About 75 percent of alcohol or

tobacco users reported an opportunity to try marijuana by

age 18, and more than 85 percent of them made the transition to marijuana use. Only about 25 percent of nonsmokers and nondrinkers were given an opportunity to try

marijuana by the same age. Of these, fewer than 25 percent began smoking marijuana within 6 years after they

were first given the opportunity. Overall, alcohol or tobacco users were seven times more likely to start using marijuana than individuals who had used neither alcohol nor

tobacco. 

Prior marijuana use was closely associated with the opportunity to try cocaine and the likelihood of young people’s

starting to use cocaine once given the opportunity. Among

the young people who were given the chance to try cocaine,

those who were already using marijuana were 15 times

more likely to use cocaine than those who did not use marijuana. About 50 percent of marijuana users used cocaine within

2 years of their first opportunity

to do so. However, among

young people who never used

marijuana, fewer than 10 percent initiated cocaine use.

In a separate but related study,

the researchers analyzed data

from 41,271 young people

who participated in the 1991

through 1994 NHSDA, investigating the relationship between the use of marijuana and

use of hallucinogens. The results showed that marijuana

users are more likely than nonusers to be offered an

opportunity to use LSD, mescaline, mixed stimulant-hallucinogens, and PCP and more likely than nonusers to try

these hallucinogenic drugs when they’re offered. By age

21, nearly one-half of the teenagers who had smoked marijuana were presented with the opportunity to try hallucinogens, compared to only one-sixteenth of those who

had not used marijuana. Once given the opportunity to

use hallucinogens, marijuana smokers were about 12 times

more likely to use hallucinogens than those who did not

use marijuana.

“These studies are the first to support the idea of two separate mechanisms linking the use of alcohol, tobacco,

marijuana, cocaine, and hallucinogens—one mechanism

34

Prior marijuana use was

closely associated with the

opportunity to try cocaine and

the likelihood of young people’s

starting to use cocaine once

given the opportunity.
35

Drug Use Associated With More Opportunities To Use,

Higher Rates of Acceptance
36

involving increased drug exposure opportunity, and a separate mechanism involving increased likelihood to use

once the opportunity occurs,” says Dr. Anthony. “Even if

there is an underlying common vulnerability or predisposition that accounts for the observed sequencing of drug

exposure opportunities and actual drug use, these observations may have implications for the design and evaluation

of drug prevention activities. Drug users often are members of social circles where drug use and experimentation

are more common and friends are likely to share drugs.

In addition to trying to persuade young people not to use

drugs, it may be worthwhile for us to persuade users not

to share their drugs with friends.”

Previous research has also shown that although males are

more likely than females to have opportunities to use

drugs, both are equally likely to make a transition into

drug use once an opportunity to try a drug has occurred.

Dr. Anthony and his colleague, Dr. Fernando Wagner, also

from Johns Hopkins University Bloomberg School of

Public Health, have made similar observations in ongoing

research studies.

Dr. Anthony believes that his research carries a strong

message for parents and pediatricians, who often neglect

the opportunity to ask children and adolescents about

whether they have had chances to try illegal drugs. As Dr.

Anthony notes, “Kids will talk to us about their chances

to try illegal drugs even when they are unwilling to talk

about actual drug use. Once the chance to try marijuana

or cocaine occurs, it is a red flag, and we need to be paying close attention to what happens next.”

“Future research in this area will be a great asset to the

development of effective drug prevention programs,” says

Dr. Etz. “It will assist us in understanding the process

through which the use of one drug is related to use of

another and help us to target prevention programs to individuals more likely to progress to advanced substance use.”

Sources

• Wagner, F.A., and Anthony, J.C. Into the world of

illegal drug use: Exposure opportunity and other

mechanisms linking the use of alcohol, tobacco, marijuana, and cocaine. American Journal of Epidemiology

155(10):918–925, 2001.

• Wilcox, H.C.; Wagner, F.A.; and Anthony, J.C.

Exposure opportunity as a mechanism linking youth

marijuana use to hallucinogen use. Drug and Alcohol

Dependence 66(2):127–135, 2002. 
Research Findings

37

Shortened Family Prevention Programs Yield Long-Lasting

Reductions in Adolescent Drug Abuse

By Robert Mathias, NIDA NOTES Staff Writer 

Volume 17, Number 2 (May 2002)

Two brief family-focused drug abuse prevention

programs have produced long-term reductions in

substance abuse among adolescents in rural Iowa

public schools who were assigned to the programs

in the sixth grade, a study funded by NIDA and

the National Institute of Mental Health has

shown. The programs may offer communities a

practical approach to effective family-based drug

abuse prevention.

The longer of the two programs reduced the proportion of students who used any marijuana,

tobacco, or alcohol in grades 6 through 10 as

well as students’ current use of alcohol and

tobacco. The shorter program decreased alcohol

use among 10th-graders significantly, along with

reducing lifetime substance use behaviors.

“The study demonstrates that brief family interventions can reduce drug use among young people during the high-risk years when they are

making the transition from childhood to adolescence,” says Dr. Richard Spoth of Iowa State

University in Ames, who led the study. Reducing

the number of children who begin substance use

during these years may have important public

health benefits because early initial use is associated with higher rates of substance dependence

in later adolescence and young adulthood, he says.

A total of 667 families of sixth-graders from 33 public

schools in Iowa were recruited for the study. The children’s

schools were randomly assigned to either a five-session

program called Preparing for the Drug Free Years (PDFY),

a seven-session Iowa Strengthening Families Program

(ISFP), or a control group. The two programs were

designed for families with young adolescents. The ISFP

was adapted from a more extensive program that had previously been evaluated in a variety of settings and with

several racial and ethnic groups.

“The purpose of modifying longer programs and trying

to replicate their results in new settings is to make them

more practical for communities to implement and for

families to participate in them,” notes Dr. Elizabeth

Robertson of NIDA’s Division of Epidemiology, Services

and Prevention Research. “The fact that the adapted programs achieved very positive results indicates they can be

whittled down and still maintain their effectiveness,” 

she says.

Staff members from the Iowa Cooperative State Research,

Education, and Extension Service of the U.S. Department

of Agriculture worked with community facilitators to

implement either PDFY or ISFP in a total of 22 schools

with 459 families whose family, school, and community

characteristics had previously been assessed. Eleven schools

with 208 comparable families were assigned to a control

group that was mailed leaflets on adolescent development

and parent-child relationships. The programs were delivered in weekly evening sessions to participating families at

the schools. Parents in PDFY attended four sessions and

were joined by their children for a final joint session. In

the relatively more intensive ISFP, parents and children

attended both separate and joint sessions for 6 weeks and

a final joint session. The weekly PDFY and ISFP sessions

sought to improve how parents and children functioned

individually and as a family in a variety of situations. Both

Substance Use Behaviors Among 

10th-Grade Students 

Lower percentages of ISFP and PDFY 10th-graders than control students had

initiated a number of substance abuse behaviors involving use of alcohol, cigarettes, and marijuana 4 years after they had received the programs in the 6th

grade.

0

10

20

30

40

50

60

Ever Used

Marijuana

Ever Smoked

Cigarettes

Ever Used Alcohol Ever Been Drunk

Without Parents

P

Percentage

ISFP

PDFY

Control
38

programs taught skills

such as effective parenting, appropriate management of family conflicts,

and how to resist peer

pressure. The development of such skills has

been linked to delayed

onset or reduction of substance abuse. 

Four years after 6th-grade

students had received the

programs, the researchers

interviewed them and

found that significantly

lower percentages of ISFP

than control 10th-graders

had ever initiated any of

five substance abuse

behaviors. Specifically,

lower percentages of ISFP

students than controls

had begun to use alcohol,

cigarettes, or marijuana; had ever used alcohol without

parental permission; or had become drunk. The proportion

of new marijuana users in the control group was 2.4 times

greater than it was among ISFP youths. Similarly, the proportion of controls who had been drunk or smoked cigarettes were 1.7 and 1.5 times greater than they were among

ISFP youths. Participants in the PDFY program also

showed lower rates of initiation of all five substance use

behaviors than controls, but only the differences in lifetime

drunkenness and marijuana use approached statistical significance. Nevertheless, the rates of new marijuana use and

ever getting drunk were 1.5 and 1.2 times greater for controls than they were for PDFY youths. Actual rates of substance use behaviors among 10th-graders in all three

groups are shown in the illustration on page 8.

Among those 10th-graders in the three groups who had

begun to use alcohol, tobacco, or marijuana, the study

found lower proportions of PDFY and ISFP students than

controls had used alcohol and tobacco in the preceding

month and marijuana during the preceding year. For

example, frequency of past-month alcohol use among

PDFY and ISFP students was about two-thirds that of

controls. Among ISFP students, past-month cigarette use

was approximately half that of control group students.

“Developmental timing is an important factor in the

long-term effects of these interventions,” Dr. Spoth says.

“Intervening at this time, in the sixth grade when kids are

experimenting with substances, probably contributes

greatly to the positive effects,” he says. The careful design

of the interventions with their theory-based focus on parenting and family interactions also is important, he adds.

The critical element affected by both programs is the parent component, says NIDA’s Dr. Robertson. “When you

provide parents with information about what to expect of

children at that age, what is typical and what is not, and

how to deal with some of the problems, you are shaping

how parents relate to their children. Changing the family

context can have a long-lasting effect because you are positively influencing the day-to-day environment of the child

over a long period of time,” she says.

Whether the findings of this study would apply to more

diverse populations in other settings remains an open

question, Dr. Robertson says. However, the original programs from which the critical elements in these programs

were derived have been successfully tested in a variety of

settings, she notes. In addition, the ISFP has been adapted

for and is now being tested with urban and rural AfricanAmericans and Native American families. 

Source

• Spoth, R.L.; Redmond, C.; and Shin, C. Randomized

trial of brief family interventions for general populations: Adolescent substance use outcomes 4 years following baseline. Journal of Consulting and Clinical

Psychology 69(4):627–642, 2001. 

Brief Family Programs Reduce Rates of Marijuana Initiation

Over 4-Year Study

Initiation of marijuana use occurred at a slower rate among students who participated in the ISFP and

PDFY programs than among those in the control group.

15

10

5

0 Percentage of New

Users

Time After Initial Assessment

ISFP= Iowa Strengthening Families Program

PDFY= Preparing for the Drug-Free Years

Control

0 Months 6 Months 18 Months

(7th Grade)

30 Months

(8th Grade)

48 Months

(10th Grade)

Control

PDFY

ISFP

(6th Grade)
Research Findings

39

New Vistas in Drug Abuse Prevention

By NIDA Acting Director Glen R. Hanson, Ph.D., D.D.S.

Volume 16, Number 6 (February 2002)

“Prevention is the best treatment” is an oft-cited maxim, and

one that certainly applies to drug

abuse. Anyone who can be influenced to avoid abusing drugs is

spared their harmful health and

social effects, including increased

risk for lethal infections, family

disruption and job loss, confusion and despair, the difficult

struggle of treatment, and—for

many—the ravages of addiction

and the ordeal of climbing back

after relapse. From society’s point

of view, drug abuse prevention

helps keep a tremendous burden—

related to disease and premature

death, lost capacity for productive

work, and crime—from being 

even worse.

The bulk of current interventions

to prevent drug abuse fall mainly

into two groups. One set is

designed to reduce risk factors associated with higher likelihood of

drug abuse and increase protective

factors associated with lower likelihood of drug abuse. When implemented in conformity with proven prevention principles

(see “Risk and Protective Factors in Drug Abuse

Prevention,” NIDA NOTES, Vol. 16, No. 6), this strategy,

the product of more than a decade of research and clinical

experience, is effective and inclusive enough to apply to

most populations. Moreover, researchers continue to learn

more about how risk and protective factors relate, and

practitioners are ever more adept at applying this knowledge. These efforts will continue to yield incrementally—

perhaps even dramatically— higher impact interventions

well into the future.

Nonetheless, there are limitations to the risk-and-protective-factors strategy. One feature that ultimately limits its

impact, for example, is the nature of the factors themselves. They tend to be fundamental or deeply entrenched

characteristics or experiences of a person, family, or community. Some are hidden, such as sexual victimization;

others are prominent in society,

such as adolescent 

depression or ready access to

drugs of abuse. As a result, traditional risk factors generally can be

modified only by relatively broad

and long-term interventions.

Certain factors may not be susceptible to modification, such as a

genetic predisposition to risk-taking. In addition, for the most

part, traditional risk factors pertain to an individual’s vulnerability to drug abuse, rather than the

actual choice to use drugs. As

important as it is to lower vulnerability, on a given day, even someone

with a relatively low vulnerability

may opt to use drugs.

The second important group of

preventive interventions complements and extends the risk-andprotective-factors strategy by focusing on the dynamic of situations,

beliefs, motives, reasoning and reactions that enter into the choice to

abuse or not to abuse drugs.

Important applications of this strategy include normative education to refute the common

belief that “everyone takes drugs,” and equipping young

people with the skills to refuse drug offers without feeling

they are losing face. This strategy is full of untapped

promise, and today likely offers the best prospects for

rapid development of more effective prevention. A few of

the many issues whose elucidation may yield improved

interventions include why even very young children tend

to expect positive experiences from drugs; how individuals’

styles for processing language and visual images affect

drug-taking decisions; the roles of curiosity and impulsivity in such decisions; and what logical processes people

typically follow when deciding to use or not use drugs. 

A recent dramatic finding in neurobiological research may

greatly increase our understanding of adolescent decisionmaking and our ability to help adolescents choose wisely

regarding drug abuse. Scientists have long suspected that

New ideas and information

have emerged recently that

hold great promise for

enhancing the impact of 

current prevention efforts.
40

the adolescent brain is still developing physically, and

researchers have now demonstrated that new neural tissue

and connections continue to form throughout the transitional years between childhood and adulthood. Further

investigation of this growth process

undoubtedly will yield important

insights relevant to some of the

cognitive issues affecting the appeal

of drugs and drug-taking decisions.

The impact on drug abuse prevention could be tremendous, especially in light of the fact that adolescence often is a critical period for

initiation of drug abuse. Most

chronic drug abusers start experimenting with intoxication in adolescence or young adulthood.

While populations are constantly

changing—and while prescription

drug abuse by older individuals

today is a serious and mounting concern—it remains generally true that people who do not abuse drugs during the

decisive years before age 25 are unlikely ever to develop a

serious drug problem.

A tighter focus on decisionmaking regarding drug abuse

should enable us to progress in a vitally important area:

preventing escalation from early, experimental drug use to

regular use, abuse, and addiction. We know that fewer

than 10 percent of people who experiment with drugs

become dependent or addicted. We also know that some

of the factors that influence whether a person will become

dependent or addicted are independent of the factors that

influence whether he or she will initiate drug abuse. For

example, research has suggested that, perhaps because of

their particular brain chemistry, some individuals dislike

the agitation cocaine can produce more than they like the

euphoria it brings—and so discontinue use after their 

initial experimentation. Interventions based upon such

factors may curtail drug abuse before it reaches critical

severity and thereby forestall most of its truly tragic health

and social consequences.

NIDA’s prevention agenda is to

aggressively pursue research on risk

and protective factors while also

seeking to identify, develop, and

integrate new science-based

approaches into existing prevention

programs. To accomplish these

goals, NIDA recently launched the

three-part Drug Abuse Prevention

Research Initiative. (See page 43,

“NIDA Conference Reviews

Advances in Prevention Science,

Announces New National Research

Initiative.”) Basic researchers will

mine new neurobiological and

other fundamental research discoveries for prevention applications. Basic, clinical, and

applied researchers and practitioners will work together in

Transdisciplinary Prevention Research Centers to synthesize knowledge from all the relevant scientific fields into

powerful new prevention packages. Researchers and State

and local practitioners will collaborate in Community

Multisite Prevention Trials to rapidly assess proposed new

prevention approaches and interventions in diverse communities and populations.

Exciting moments in science occur when the gradual accumulation of knowledge suddenly gives rise to new perspectives with the promise of new solutions to problems of 

living. In the area of drug abuse prevention, this is such

a moment, and NIDA is moving swiftly to take full

advantage of its potential. 

It remains generally true that

people who do not abuse

drugs during the decisive

years before age 25 are

unlikely ever to develop a 

serious drug problem.
Research Findings

41

NIDA Conference Reviews Advances in Prevention Science,

Announces New National Research Initiative

By Barbara Cire, NIDA NOTES Associate Editor 

Volume 16, Number 6 (February 2002)

A review of current, effective drug

abuse prevention programs and the

announcement of a new NIDA 

initiative were among the highlights

of the Second National Conference

on Drug Abuse Prevention Research

held August 9 and 10 in Washington,

D.C. Almost 900 participants from

all 50 States, the District of Columbia,

Puerto Rico, and 13 foreign countries

attended the meeting, which was sponsored by NIDA and the Robert Wood

Johnson Foundation.

“A particular focus of this conference

is to examine how prevention programs can be implemented at the

local level,” said Dr. Elizabeth

Robertson, chief of NIDA’s

Prevention Research Branch. 

“In 20 years of research, we have

learned that there are modifiable risk

and protective factors, particular

points of vulnerability to drug use and

abuse, and some basic prevention

principles which we summarized in the first-ever sciencebased guide to prevention, Preventing Drug Use Among

Children and Adolescents,” said then-NIDA Director Dr.

Alan I. Leshner in his remarks to participants. “Research

has answered many questions, but others remain. We now

target risk and protective factors in our prevention programs, but what are the factors that influence the actual

decision to use drugs? 

“Over the next 2 years, NIDA will establish the National

Drug Abuse Prevention Research Initiative,” said Dr.

Leshner. “Our goal is to provide the resources to bring the

full power of science to bear on the challenge of developing

effective drug abuse prevention programs. The Initiative

will have three components: Basic Prevention Science

Research, Transdisciplinary Prevention Research Centers

(TPRCs) and Community Multisite Prevention Trials.”

The initiative is intended to stimulate research to translate

new knowledge into new interventions, Dr. Leshner noted.

The Basic Prevention Science Research component will

examine ideas from the sociological, biological, behavioral,

and cognitive literature, looking for new

information with the potential to inform the

development and pilot-testing of new prevention interventions. The TPRCs will support collaborative projects by basic, applied,

and clinical researchers across the country.

They will focus on identifying and addressing the major knowledge gaps that affect the

work of State and local prevention service

providers.

The Multisite Trials will test the effectiveness of drug abuse prevention programs in

diverse populations and locations. “The trials will examine the features that influence

the successful adoption, adaptation, sustainability, and outcomes of science-based interventions in large-scale field trials,” Dr.

Leshner said.

The conference also featured panel discussions on using risk and protective factors in

prevention, identifying effective features in

prevention interventions, assessing substance

abuse in the community, and building multicomponent community programs. Smallgroup workshops and lunchtime discussion groups gave

participants an opportunity to learn about particular programs in detail and share lessons learned in their own

communities.

Risk and Protective Factors

Dr. David Hawkins of the Social Development Research

Group at the University of Washington in Seattle summarized the risk and protective factors that can influence

whether young people will use drugs. “Over the last 20

years, longitudinal studies have identified many factors

that predict youth violence, substance abuse, and other

problem behaviors,” he said. “Such factors exist in every

domain of life: individual, family, peers, school, and community. We must reduce the risk factors and promote the

development of protective factors on all levels: individual,

family, school, peer, and community.” (See “Risk and

Protective Factors in Drug Abuse Prevention,” NIDA

NOTES, Vol. 16, No. 6) There is a growing list of tested,

“Messages should be pretested for their

effectiveness and appropriateness to the

target audience.”

—Dr. Joseph Cappella

University of Pennsylvania,

Philadelphia
42

effective prevention

programs that have

been shown to reduce

risks, enhance protection, and prevent

adolescent substance

abuse, Dr. Hawkins

noted.

Dr. Sheppard Kellam

of the American

Institutes for

Research in

Washington, D.C.,

discussed a schoolbased intervention

called the “Good

Behavior Game

(GBG).” Previous

research has shown

that aggressive and disruptive behavior among first-graders

is associated with later aggression, violence, drug abuse,

and school dropout. The GBG was originally developed in

the late 1960s to help teachers organize and manage classroom behavior and to teach young children how to behave

as students. Accepting rules of classroom behavior, concentrating and being ready to work, participating appropriately in classroom teaching and with classmates, and

learning were the focus of the GBG. In 1985–1986, Dr.

Kellam and his colleagues implemented the GBG as a prevention intervention in 40 first-grade classrooms in 18

representative elementary schools in Baltimore.

First- and second-grade children were assigned to one of

three teams in their classroom. During the game, teams

were penalized if any team member did not follow the

rules, for example,

by speaking out of

turn or getting out

of their seats without permission.

Teams with four or

fewer penalties at

the end of the

game were rewarded with verbal

praise from the

teacher, special

snacks, or extra

time at recess;

teams with more

than four penalties were not

rewarded. At first,

the game was

played three

times a week for

10 minutes at a time. The length of time the game was

played increased until it reached a weekly maximum of 

3 hours. 

Six years later, preliminary analysis of followup data

revealed that aggressive behavior and smoking initiation

were lower among children who received the classroom

intervention compared to those who had not, particularly

among boys who had been disruptive or aggressive in first

grade. In a recent followup of the participants at age 19 to

22, preliminary analyses indicate that the prevalence of

antisocial personality disorder among the most aggressive

boys appears to be three to four times lower compared to

aggressive boys who did not receive the intervention.

These results underscore the importance of early socializing children into the role of student, particularly those at

increased risk of learning and/or behavioral problems.

Implementation of Interventions

Dr. Linda Dusenbury of

Tanglewood Research, Inc., in

Greensboro, North Carolina,

discussed the effective implementation of interventions. She noted that effective programs are research-based and typically include social resistance training to help students refuse offers to use drugs,

as well as information that counters their erroneous perceptions that drug use is widespread among their peers.

Effectiveness also depends on the “dosage”—how much of

a program is delivered—and the quality—how well the

program is delivered, she said. “Ineffective prevention

strategies include scare tactics and moral messages,” Dr.

Dusenbury said. “An exclusive focus on information about

different drugs and testimonials from recovering addicts

doesn’t work very well, either.” 

Dr. Dusenbury noted that when programs are implemented, there is always a tension between fidelity to the program as it was originally designed and the flexibility

required to adapt it to local needs. “If some aspect of a

particular program is not working in your community and

you want to change it, it’s best to talk to the people who

developed the program to make sure your adaptation does

not violate key principles of the program,” Dr. Dusenbury

said. “This step helps you and provides the developers

with useful feedback.”

“We must reduce the risk factors and

promote the development of protective

factors on all levels: individual, family,

peers, school, and community.” 

—Dr. David Hawkins,

University of Washington,

Seattle

“Previous research has shown that aggressive

and disruptive behavior among first-graders

is associated with later aggression, violence,

drug abuse, and school dropout.” 

—Dr. Sheppard Kellam, 

American Institutes for Research,

Washington, D.C. 

“We will examine how prevention

programs can be implemented at the

local level.” 

—Dr. Elizabeth Robertson, 

chief of NIDA’s Prevention 

Research Branch
43

Dr. Christopher Ringwalt of the Pacific Institute for

Research and Evaluation in Chapel Hill, North Carolina,

reported preliminary results of a study to identify the prevention curricula being used in middle schools and junior

high schools across the country and to determine how

many schools were using research-based curricula. Data

were collected in 1999 from 1,905 public and private

schools via a questionnaire filled out by school staff who

taught substance abuse prevention classes.

The study found that only 25 percent of the schools surveyed used at least one research-based curriculum.

Respondents were more likely to use didactic instruction

methods such as lectures and classroom discussions than

interactive methods such as small-group discussions and

role-playing activities when presenting information.

The most frequently emphasized content area

was knowledge of drugs and their effects; the

least emphasized area was drug refusal skills.

“These results demonstrate a considerable gap

between current school prevention practices

and our understanding of effective curricula

and their components,” said Dr. Ringwalt.

Mass Media Campaigns

An overview of the key elements that make

mass media campaigns effective was presented

by Dr. Joseph Cappella of the Annenberg

School of Communication at the University of

Pennsylvania in Philadelphia. He began by noting that success is contingent upon clearly

defining a target audience, understanding their

prevailing attitudes and beliefs, and crafting

engaging and persuasive messages that are presented over the long term. These messages

should be pretested for their effectiveness and

appropriateness to the target audience.

Well-designed campaigns, Dr. Cappella noted,

can affect behavior, as demonstrated by research on smoking and drug use among teens. For example, an antimarijuana public service announcement (PSA) campaign

developed by NIDA-supported researchers at the

University of Kentucky in Lexington decreased marijuana

use by more than 25 percent among high-sensation-seeking adolescents—a group particularly at risk for drug

abuse. (See “Television Public Service Announcements

Decrease Marijuana Use in Targeted Teens,” V16-4,

October 2001.) The PSAs included messages especially

designed to appeal to the sensation-seeking teens and ran

for 4 months during TV programs popular with this

group. 
Research Findings

44

The Many Faces of MDMA Use Challenge Drug Abuse Prevention

By Robert Mathias, NIDA NOTES Staff Writer 

Volume 16, Number 5 (December 2001)

Three NIDA-funded ethnographic studies presented at

the MDMA/Ecstasy Conference illustrate the diversity

and complexity of MDMA use in the United States. The

studies showed both similarities and differences in patterns

of MDMA use and associated sexual behaviors among

homosexual men in Boston and New York City, predominantly white heterosexual users in central Ohio, and a

racially diverse group of users in Hartford, Connecticut.

The studies employed a variety of research techniques,

such as on-site observation and interaction with ecstasy

users in clubs, informal and structured interviews, and

small focus groups, to ascertain who uses MDMA, their

patterns of drug use and related behaviors, and the settings in which they use drugs.

Preliminary findings from these studies suggest that targeted drug abuse prevention approaches that address specific

factors that are associated with MDMA use by different

types of users and in different regions of the country are

needed to reduce MDMA abuse. Further research to

understand the factors that increase or reduce the risks for

drug use in these groups is needed to shape prevention

initiatives, the researchers indicated.

MDMA Use Among Men Who Have Sex With Men 

A field study conducted by Dr. Patricia Case of Harvard

Medical School in Boston found considerable individual,

group, and regional variations in patterns of MDMA use

among club-drug-using men who have sex with men

(MSM) in Boston and New York. More than 50 percent

of men interviewed in the study frequently used MDMA

in combination with other drugs and 11 percent had

injected mainly anabolic steroids within the last 3 months.

MSM reported that MDMA use usually occurs with other

drugs, including ketamine, cocaine, methamphetamine,

and Viagra. Some users primarily engage in uncontrolled

drug use, others also take MDMA frequently but according to a set schedule with other drugs to achieve special

effects, and still others use MDMA occasionally in connection with special circumstances or holidays.

The MSM in this study were very sexually active and

reported unprotected sex while using MDMA although

not so often as with other drugs, such as methamphetamine. MDMA prevention messages have had little effect

on MSM. This population expressed more concern about

the risks of GHB (gamma-hydroxybutyrate), a central 

nervous system depressant, because of reported overdose

deaths from that drug in both cities.

MDMA Use in Central Ohio

Dr. Robert Carlson and colleagues of Wright State University School of Medicine in Dayton, Ohio, conducted a

pilot study of MDMA use among 28 individuals in 2

focus groups in Dayton and Columbus. Participants were

evenly divided between men and women who were almost

exclusively heterosexual. Like the MSM study, the Ohio

study showed tremendous variations in patterns of

MDMA use.

One-third of the study population said they had used

other club drugs, such as ketamine and GHB, and high

alcohol use was common. Dance clubs were popular 

settings for MDMA use among college students and 

other young adults, who tended to use MDMA to

enhance sociability. MDMA users at raves were younger,

less educated, and more likely to have a drug-using

lifestyle than were the club-goers. Participants said they

also used MDMA at parties, lakes, beaches, high schools,

and in cars.

“MDMA is seen as a relatively benign drug,” Dr. Carlson

said. “Most people hear of very few negative consequences

from friends, although they do express concern about

adulterants in the pills they are getting.” None of the participants reported any negative effects of MDMA use on

memory, cognition, or work performance. Condom use

during sex appeared to be the norm, but several women

reported having sex with men they had not intended to be

with after taking MDMA.

MDMA Use Among Urban Youth in Hartford,

Connecticut

Dr. Jean Schensul, of the Institute for Community

Research in Hartford, Connecticut, reported information

from observations and interviews with urban youths in

party and club settings combined with survey data

obtained during a 15-month study of youths in Hartford.

Study participants were 16 to 24 years old, 70 percent

male, 40 percent Hispanic, 38 percent African American,

and 22 percent Caucasian, Asian, and mixed race or ethnicity. MDMA use in this population is linked to their
45

social networks, club-going, and parties. MDMA is 

often used with other drugs, including marijuana, PCP,

and alcohol.

“These youth have limited access to accurate sources of

information and are uninformed about the risks of

MDMA use and drug mixing,” Dr. Schensul said. They

are exposed to popular hip-hop magazines and rap music

lyrics that promote the connection between ecstasy, the

“good life,” and better sex. The study shows that MDMA

use has spread from the suburbs to the city and is increasing the already high levels of risk of unprotected sex and

sexually transmitted diseases among these economically

vulnerable young people. The findings suggest that 

culturally and developmentally appropriate prevention

approaches that focus on reducing harmful behaviors are

needed for this population, Dr. Schensul said.
Research Findings

46

Television Public Service Announcements Decrease Marijuana Use

in Targeted Teens

By Kimberly R. Martin, NIDA NOTES Contributing Writer

Volume 16, Number 4 (October 2001)

NIDA-supported researchers have helped clarify the 

necessary elements in effective anti-drug public service

announcements (PSAs) directed at high-sensation-seeking

adolescents.

NIDA researchers have previously shown that highsensation-seekers—individuals characterized by their need

for new, emotionally intense experiences and the willingness to take risks to obtain these experiences—are at

greater risk for using marijuana and other drugs and for

using them at an earlier age than other individuals.

Using a prevention approach developed from previous

NIDA-supported studies, the researchers produced five

anti-marijuana PSAs. The dramatic and attention-getting

PSAs were aired during programs that appealed to highsensation-seekers such as action-oriented television shows.

The media placement was supported by paid as well as

donated advertising to ensure the most effective outreach

to the target audience.

“To appeal to high-sensation-seekers, a PSA must be dramatic, intense, and highly original,” says Dr. Philip

Palmgreen, the research team leader at the University of

Kentucky in Lexington. “An effective PSA needs to show

the negative consequences that can occur as a direct result

of drug use. For example, high-sensation-seekers need to

see that they can end up in a wheelchair, lose their job, or

lose their girlfriend or boyfriend as a result of drug use.

We found that the threat of death is not a deterrent

because high-sensation-seekers do not believe that death is

a real possibility,” he says.

The PSAs were aired from January through April 1997 in

Fayette County, Kentucky, and from January through

April 1998 in Fayette County and Knox County,

Tennessee. One hundred students in 7th through 10th

grade were selected each month by random phone calls

and asked to participate in the study. The students were

interviewed to determine whether they saw the PSAs and

their attitudes toward and whether they used marijuana

and other drugs. Questions also were asked to determine

their degree of sensation-seeking. More than 70 percent of

the targeted age groups watched at least three PSAs per

week, the researchers say.

Marijuana use declined substantially among teens during

the campaigns in both counties and residual effects of the

campaigns were evident for several months. According to

Dr. Palmgreen, the second campaign in Fayette County

had a “booster effect,” resulting in further declines.

Overall, marijuana use decreased by 38 percent in Fayette

County. In Knox County, marijuana use declined among

high-sensation-seeking teens by 26.7 percent.

“We have shown that, for PSAs to be effective, they must

be designed for a specific audience and must air frequently

during programs watched by that audience,” says Dr.

Palmgreen. “PSAs typically are shown during donated 

airtime. However, the trend toward paid placements of

PSAs, as in various campaigns across the country, is a very

positive approach.”

Source

• Palmgreen, P.; Donohew, L.; Lorch, E.P.; Hoyle, R.;

and Stephenson, M.T. Television campaigns and adolescent marijuana use: Tests of sensation seeking targeting. American Journal of Public Health 91(2):292-

296, 2001.

Drs. Philip Palmgreen (left) and Lewis Donohew

review a public service announcement at the 

University of Kentucky.
Research Findings

47

NIDA Initiative Targets Increasing Teen Use of Anabolic Steroids

By Patrick Zickler, NIDA NOTES Staff Writer

Volume 15, Number 3 (August 2000)

To reverse the rising use of anabolic steroids by high

school-age children, NIDA and seven national partners

have launched an initiative designed to alert the public

about the risks associated with anabolic steroid use.

“The most recent data from our Monitoring the Future

survey tell us that the trends in use of these drugs and in

teenagers’ attitudes about them are going in the wrong

direction,” said NIDA Director Dr. Alan I. Leshner at a

Washington, D.C., press conference to announce the initiative. “More than a half million 8th- and 10th-grade students are now using these dangerous drugs, and increasing

numbers of high school seniors say they don’t believe the

drugs are risky.”

Anabolic steroids are synthetic compounds that mimic the

action of the male sex hormone testosterone. The drugs

have some medical uses, but they also are abused by some

athletes and sports enthusiasts who want to increase muscle mass and improve performance. Some teens use them

because of concern about body image.

In adolescents, anabolic steroid abuse can halt bone

growth and has been associated with damage to the heart,

kidneys, and liver. In males, steroid abuse can lead to

impotence, shrunken testicles, and breast enlargement. In

females, the drugs’ effects include menstrual irregularities,

growth of body hair and loss of scalp hair, a deepened

voice, and reduction in breast size. Some of these biological

effects are irreversible. Use of anabolic steroids also has

been linked to increased and unpredictable levels of

aggression in human and animal studies.

NIDA’s initiative includes a new Web site-www.steroid

abuse.org-that provides science-based information about

the risks and prevention of steroid abuse. NIDA has also

released an updated Research Report on anabolic steroids

as part of the nationwide multimedia initiative (see

“About Anabolic Steroid Abuse,” NIDA NOTES, Vol. 15,

No. 3). NIDA and its partners will distribute 250,000

copies of a special Community Drug Alert Bulletin on

anabolic steroid abuse and will place 500,000 “art

cards”—colorful postcards with messages about the harmful effects of steroid abuse-in gyms, bookstores, restaurants, and clubs in Washington, D.C., Los Angeles,

Miami, Baltimore, Seattle, and Indianapolis.

The Institute’s partners in the initiative include the

National Collegiate Athletic Association, the American

Academy of Pediatrics, the American College of Sports

Medicine, the National Association of School Nurses, the

National Federation of High Schools, International

Students in Action, and Dr. Drew Pinsky, a physician who

hosts discussions about relationships and sexual behavior

on MTV’s “Loveline” and the Web site www.drDrew.com.

The press conference announcing the initiative was followed by a scientific session at which NIDA-supported

scientists presented summaries of research on anabolic

As part of NIDA’s anabolic steroids initiative, the Institute

has distributed more than 500,000 “art” cards-colorful 

postcards with messages about the harmful effects of steroid

abuse-in gyms, restaurants, bookstores, and clubs. 

Dr. Linn Goldberg (left) of Oregon Health Sciences University,

explains the Adolescent Training and Learning to Avoid Steroids

(ATLAS) program to reporters at a science session following the

NIDA press conference.
48

steroids. Dr. 

Charles Yesalis of

Pennsylvania State

University discussed

the history and social

context of steroid

use and abuse. Dr.

Linn Goldberg and

Dr. Diane Elliot of

the Oregon Health

Sciences University in Portland described the Adolescent

Training and Learning to Avoid Steroids (ATLAS) program, a science-based prevention program that uses a

team-centered approach to educate young male athletes

about the risk and protective factors associated with

steroid use. The researchers are currently developing a

similar program—Athletes Targeting Healthy Exercise and

Nutrition Alternatives (ATHENA)—to prevent eating disorders and abuse of steroids and other body-shaping drugs

by young women on school-sponsored athletic, dance and

drill, and rally teams. Dr. Harrison Pope of the McLean

Hospital in Belmont, Massachusetts, discussed results of a

study designed to examine the effects of steroids on mood

and increased aggression—a phenomenon referred to as

“roid rage.” The research, which involved 56 men who

regularly work out at gyms and health clubs, revealed

increased aggressive behavior in some participants who

received testosterone in dosages smaller than those typically used by athletes or body-builders. Dr. Marilyn

McGinnis of Mount Sinai School of Medicine in New

York City provided additional evidence that steroid use

can result in aggressive behavior. She described recently

completed laboratory studies in which rats with elevated

levels of steroids exhibited unprovoked aggression toward

passive, nonthreatening rats as well as intensely aggressive

responses to provocation.

For More Information

The NIDA Research Report “Anabolic Steroid Abuse”

(NCADI publication #PHD561) can be obtained from

the National Clearinghouse for Alcohol and Drug

Information, P.O. Box 2345, Rockville, MD 20847;

phone 800-729-6686; fax 301-294-5516; e-mail

info@health.org. The report and other information about

anabolic steroids can be found at the special NIDA Web

site: www.steroidabuse.org.

“Art” cards like this

and the one on page 1

help spread the word

about the harmful

effects of steroids.
Research Findings

49

Putting Science-Based Drug Abuse Prevention Programs to Work in

Communities

By Robert Mathias, NIDA NOTES Staff Writer 

Volume 14, Number 6 (March 2000)

NIDA-supported studies are defining ways to get scientifically tested drug abuse prevention programs applied in

communities across the Nation. This complex line of

research is developing new partnerships and strategies that

can enable both rural and urban communities to select

and sustain effective prevention programs that promote

young people’s well-being and deter drug use and other

harmful behaviors.

Scientists have shown that programs that help parents and

children function better individually and as a family can

reduce substance abuse among general populations of

young people. However, the potential of such researchbased family and school competency-building programs

has not been fully realized because such programs are not

being widely used in communities across the Nation.

“Many challenges must be overcome to implement empirically supported programs on a large scale,” says Dr.

Richard Spoth of Iowa State University in Ames. People

seeking to adopt prevention programs often don’t have

good information about scientifically tested programs, he

says. In addition, they often lack the personnel and time

required to implement such programs faithfully.

Over the last 7 years, Dr. Spoth has led a series of interrelated studies called Project Family. The project, which is

funded by NIDA, the National Institute of Mental

Health, and other Federal agencies, has developed some

promising ways to use existing community service delivery

systems to facilitate putting youth- and family-focused

prevention science into community practice. For example,

Project Family researchers have developed partnerships

with the Iowa Cooperative State Research, Education, and

Extension Service of the U.S. Department of Agriculture.

The Strengthening Families Program addresses risk and

protective factors for drug abuse and other problem

behaviors. In the program, parents and children work

together to improve their ability to communicate and to

resolve problems at home and at school. 

Extension Service agents work in nearly every county in

the United States and are dedicated to serving families and

youth. This network of professional practitioners has a

long history of disseminating the latest scientific information for the benefit of residents of both rural and urban

communities. Programming and information provided to

local residents cover a wide spectrum of topics ranging

from child development, family relations, and consumer

economics to weed science and crop management.

The Extension Service network has helped Project Family

researchers engage community residents to help with the

project. For example, Extension Service agents have

involved schools in research evaluating family and youth

competency-building programs and have recruited and

helped train local residents to deliver the programs.

Extension Service agents also have assisted in such tasks 

as assessing family needs, identifying factors affecting 

family engagement in prevention programs, and carrying

out strategies to disseminate effective family and youth

programs.

One of the programs developed and disseminated through

this research-Extension-community partnership is a brief

family-focused prevention program called the Iowa

Strengthening Families Program (ISFP). Adapted for general populations by Dr. Virginia Molgaard of Iowa State

University from a prior, more intensive program, the

seven-session ISFP was designed to improve parents’ 
50

family management practices and communications skills

and children’s personal skills, social skills, and ability to

deal with peer pressure. The program was tested with 161

families of 6th graders enrolled in Iowa public schools.

Children who took part in the program when they were in

sixth grade were significantly less likely to begin using

drugs and alcohol or to progress to more serious substance

use than their peers who did not participate in the program, according to followup studies conducted at regular

intervals over the last 4 years. For example, 48 months

after the initial assessment, the proportion of new marijuana users among youths who didn’t participate in the

ISFP was 2.4 times greater than it was among youths who

did participate. Furthermore, the divergence in drug use

between youths who received the program in the sixth

grade and those who didn’t has widened in the 4 years

since the study’s pre-intervention assessment, according to

a recent evaluation.

Once Project Family research demonstrated the effectiveness of the Iowa Strengthening Families Program, the

State Extension Service took the lead in disseminating the

program through its statewide network, Dr. Spoth says. To

date, the Extension Service has trained more than 600

group leaders to deliver the ISFP, and the program has

been offered in 91 communities in Iowa.

“Using the Extension Service as the mechanism to 

replicate these programs in other communities is an 

exciting way to use an existing delivery system to get 

effective programming into the local communities,” says

Dr. Elizabeth Robertson of NIDA’s Division of

Epidemiology, Services, and Prevention Research. “Similar

types of service delivery systems across the country could

be tapped in the same way,” she says. “We’re working to

identify such systems and tap them to disseminate effective drug abuse prevention programs.”

In the last 2 years, Project Family has been working extensively in Iowa with another major service delivery system—

the public schools—to implement its latest study, the

Capable Families and Youth project. This NIDA-funded

study will assess whether adding the Iowa Strengthening

Families Program to a scientifically proven school-based

prevention component has a greater impact on children’s

substance abuse and other health behaviors than the

school-based program alone.

“Comprehensive prevention programs that include school,

family, and community components require effective partnerships to implement and sustain them,” Dr. Spoth says.

“We’re integrating the school system and its technical

assistance infrastructure with the Extension Service as a

way to implement these kinds of programs,” he says. (See

“The Next Step in Dissemination Proven Prevention

Programs?” NIDA NOTES, Vol. 14, No 6.)

Sources

• Spoth, R. and Molgaard, V. Project Family: A partnership integrating research with the practice of promoting family and youth competencies. In: T.R. Chibucos

and R.M. Lerner (eds.). Serving Children and Families

Through Community-University Partnerships: Success

Stories, Boston: Kluwer Academic Publishers, pp. 127-

137, in press.

• Spoth, R.; Reyes, M.L.; Redmond, C.; and Shin, C.

Assessing a public health approach to delay onset and

progression of adolescent substance use: Latent transition and loglinear analyses of longitudinal family preventive intervention outcomes. Journal of Consulting

and Clinical Psychology, in press. 

“Using the Extension Service... 

is an exciting way to use an 

existing delivery system to get 

effective programming into the 

local communities.” 
Research Findings

51

Studying Comprehensive Drug Abuse Prevention Strategies

Volume 14, Number 5 (December 1999)

In the early 1980s, NIDA began to encourage research on

comprehensive drug abuse prevention programs that

involve many components of a community. The theory

behind this approach is that children are more likely to

pay attention to antidrug messages that are repeated

throughout the community than they are to heed messages from only one source, such as in school or at home.

One of the first of these comprehensive prevention programs was the Midwestern Prevention Project conducted

by Dr. Mary Ann Pentz and her colleagues at the

University of Southern California in Los Angeles. The

research program was first implemented in Kansas City,

Kansas, and Kansas City, Missouri, in 1984 and later

replicated in Indianapolis, Indiana, starting in 1987.

The program involved schools, mass media, parents, community, and health policymakers. Sixth- and seventhgraders were taught in school how to resist social influences to use drugs. This learning was reinforced through

public service announcements and news stories. Parents

were encouraged to help their children on drug abuse prevention homework assignments and to talk with their

children about drugs. Volunteers from the community

provided leadership, developed community antidrug campaigns, and raised funds for related prevention activities.

Finally, the community established policies that discouraged the use of drugs, cigarettes, and alcohol in schools, at

work, and in public places.

Research findings indicated that students in the 107 participating schools in Kansas City and Indianapolis used

significantly less marijuana, cigarettes, alcohol, and

cocaine than did students whose schools did not participate. Substance abuse increased for both groups of students as they got older, but the increase was substantially

less for students in participating schools.

Data from the Indianapolis study showed that the program could also reduce the use of marijuana, cigarettes,

and alcohol by 6th- and 7th-graders who were already

users of these substances. “Studies have shown that young

people who use drugs and alcohol earlier than their peers

are particularly likely to continue to abuse these substances later, so the fact that this program reduced substance use in this high-risk group was particularly promising,” says Dr. William Bukoski of NIDA’s Division of

Epidemiology, Services, and Prevention Research.

“Our studies have shown that a substance abuse prevention strategy that involves many components of the community can slow the rate of increase of drug, alcohol, and

cigarette use among early adolescents and also decrease the

use of these substances by adolescents who are already

using them,” says Dr. Pentz. “This strategy works because

it changes social norms and expectations. Changing social

norms about drug use changes drug use behavior in turn.”
Research Findings

52

Student Use of Marijuana Linked to Perceptions of Risk

Volume 14, Number 4 (November 1999)

Many American teenagers today do not believe that smoking marijuana is dangerous. That was one of the conclusions of a recent study, by Dr. Jerald G. Bachman and colleagues at the University of Michigan in Ann Arbor, that

examined changing attitudes of high school students

toward the use of marijuana. The study is based on an

extensive review of data from NIDA-supported annual

surveys of 8th-, 10th-, and 12th-graders. The surveys,

which together make up the ongoing Monitoring the

Future project, have collected data on drug use from high

school seniors since 1975. Data from 8th- and 10thgraders have been collected since 1991.

The percentage of high school seniors who used marijuana

at least once during the past year decreased from 50.8 percent in 1979 to 21.9 percent in 1992, before rising steadily to 37.5 percent in 1998. While use rose, the perception

of harm from use declined from 76.5 percent in 1992 to

58.5 percent in 1998. Those who disapproved strongly of

regular use dropped from 90.1 percent in 1992 to 81.2

percent in 1998.

Dr. Bachman’s group’s statistical analysis showed that the

simultaneous rise in use and decline in perceived harmfulness during the mid-1990s was more than simple coincidence. To account for this waning concern about the dangers of marijuana, the researchers suggest that the decline

in drug use in the 1980s may have led to a “lowering of

the guard” of government, schools, mass media, and families. News coverage of drug issues fell substantially in the

early 1990s, and fewer antidrug messages were aired during prime-time television programs, the researchers note.

Young people pay close attention to realistically and creatively presented information about the risks of drug use,

the researchers suggest. “Presenting this kind of information on the risks and consequences of marijuana use only

once does not do the job,” says Dr. Bachman. “The message must be repeated regularly so we don’t lose students

from one year to the next.” 
Research Findings

53

Ethnic Identification and Cultural Ties May Help Prevent Drug Use 

By Patrick Zickler, NIDA NOTES Staff Writer 

Volume 14, Number 3 (September 1999)

Among Puerto Ricans, African Americans, and Asians,

cultural influences and ethnic identification may significantly influence drug use. Studies conducted by NIDA

researchers in New York City suggest that Puerto Rican

and African-American adolescents who strongly identify

with their communities and cultures are less vulnerable to

risk factors for drug use and benefit more from protective

factors than do adolescents without this identification. In

San Francisco, NIDA-supported research demonstrated

different patterns of drug use among different subgroups

of the Asian community. These findings suggest that

incorporating ethnic and cultural components into drug

abuse prevention programs can make these programs 

more effective.

In one study, Dr. Judith Brook at the Mount Sinai School

of Medicine in New York City examined the extent to

which ethnic and cultural factors influenced drug-related

behavior in Puerto Rican adolescents. She and her colleagues interviewed 275 males and 280 females aged 16 to

24. The researchers asked the participants to describe the

importance in their lives of cultural and ethnic factors

such as observation of Hispanic holidays and customs,

preference for speaking Spanish or English, feelings of

attachment to their ethnic group, ethnic affiliation of their

friends, and the value placed on the family. The participants also answered questions designed to assess their personal risk for drug use; these risk factors included the use

of drugs by parents or siblings, peer use or tolerance of

drug use, perception of the riskiness of drug use, and the

availability of illegal drugs in their environment. The participants were categorized into stages of drug use: no

reported drug use, used alcohol or tobacco only, used marijuana but no other illicit drug, or used illicit drugs other

than or in addition to marijuana.

“Other studies have looked at ethnic identification in isolation, not as an interactive part of a young person’s cultural and social context,” Dr. Brook says. “We wanted to

determine the extent to which ethnic and cultural factors

might mitigate risk factors or enhance protective factors

and lead to lower stages of drug use. We found that strong

ethnic identification acts to offset some risks, resulting in

less drug use.

“For example, strong identification with Puerto Rican cultural factors offsets drug risks such as a father’s drug use,

peer tolerance of drugs, and the availability of drugs.

Identification with Puerto Rican friends offsets risks associated with family tolerance for drug use and drug availability,” Dr. Brook notes. 

Ethnic identification also serves to amplify the effect of

protective factors, Dr. Brook says. For example, among

participants whose siblings were not drug users, those with

a strong Puerto Rican affiliation were significantly more

likely to be in a lower stage of drug use than those whose

affiliation was weaker.

In a related study that focused on late-adolescent African

Americans in New York City, Dr. Brook and her colleagues found a similar interaction between ethnic and

cultural identification and drug use. The study involved

627 participants—259 males and 368 females—ages 

16–25 years. 

The researchers found that components of ethnic identity—

such as awareness of African-American history and tradition, identification with African-American friends, or participation in African-American cultural activities such as

Kwanzaa interacted with other factors to reduce risk or to

enhance protection. 

“In isolation, few specific components of ethnic identity

play a role as main effects on drug use. Instead, they act in

combination with family, personality, or peer influences to

blunt the negative impact of risk factors and magnify the

positive value of protective factors,” Dr. Brook says.

“Together, the research with Puerto Rican and AfricanAmerican populations points out the importance of incorporating ethnic identity into drug programs,” Dr. Brook

concludes. “It can be a valuable part of drug prevention

programs in communities and can also be applied to individual treatment programs.”

Adolescents who strongly identify

with their communities and cultures

are less vulnerable to risk factors 

for drug use. 
54

Cultural Differences Lead to Different Patterns of

Drug Use

In another NIDA-supported study, Dr. Tooru Nemoto

and his colleagues at the University of California, San

Francisco, have identified patterns of drug use among

Asian drug users that are unique to ethnicity, gender, age

group, and immigrant status. 

“Large multiracial studies have not distinguished between

Asian ethnic groups,” Dr. Nemoto says. “The purpose of

our study was to describe the patterns of drug use in

Chinese, Filipino, and Vietnamese groups and to assess

the relationship between cultural factors and drug use

among the groups.”

The San Francisco study was based on qualitative interviews with 35 Chinese, 31 Filipino, and 26 Vietnamese

drug users who were not enrolled in treatment programs.

All participants were 18 years or older, with an average age

of 32.5, and had used illicit drugs more than three times

per week during the preceding 6 months. Overall, immigrants and women represented 66 percent and 36 percent,

respectively. However, all Vietnamese were immigrants. 

Overall, participants born in the U.S. began using drugs

at an earlier age—15 years—than did immigrant Asians—

19 years—and were more likely than immigrants to use

more than one drug. In general, women started drug use

at about the same age as men-about 17.5 years-but ethnic

groups showed a varied pattern. Chinese women began

earlier—at 15.2 years—than Chinese men—at 18.5 years.

Filipino women began using drugs later-at 15.5 years—

than Filipino men—at 13.1 years. Vietnamese women in

the study started drug use much later—at 27.8 years—

than did Vietnamese men—at 19.9 years.

Dr. Nemoto and his colleagues identified differences in

drug use among the ethnic groups. Filipino drug users

were most likely to have begun drug use with marijuana,

while Vietnamese drug users in the study most often 

started with crack or powder cocaine. Chinese and

Vietnamese were twice as likely as Filipinos to be using

crack as their current primary drug. Filipinos were four

times more likely to be using heroin than were Chinese or

Vietnamese. Filipino study participants were more likely

than Chinese or Vietnamese to be injecting and less likely

to be smoking drugs. There were also significant differences in the characteristics of drug user networks among

the ethnic groups. For example, Filipinos were more than

twice as likely as Chinese or Vietnamese participants to

use drugs in groups that included members of other races

or ethnic groups.

“These differences among ethnic groups have important

implications for the way we design programs aimed at

Asian drug users,” Dr. Nemoto says. “Prevention programs

should address the common factors among Asian drug

users, such as stigma associated with injection drug use,

but we should also be careful to incorporate factors that

are unique to each target group.” 

Sources 

• Brook, J.S., et al. Drug use among African Americans:

Ethnic identity as a protective factor. Psychological

Reports 83:1427-1446, 1998.

• Brook, J.S.; Whiteman, M.; Balka, E.B.; Win, P.T.;

and Gursen, M.D. Drug use among Puerto Ricans:

Ethnic identity as a protective factor. Hispanic Journal

of Behavioral Sciences 20(2):241-254, 1998.

• Nemoto, T., et al. Drug use behaviors among Asian

drug users in San Francisco. Addictive Behavior (in

press). 
Research Findings

55

Steroid Prevention Program Scores With High School Athletes

By Robert Mathias, NIDA NOTES Staff Writer

Volume 12, Number 4 (July/August 1997)

A NIDA-funded drug abuse prevention program is 

showing high school football players that they do not 

need to take anabolic steroids to build powerful muscles

and improve athletic performance. By educating student 

athletes about the harmful effects of anabolic steroids 

and providing nutrition and weight-training alternatives

to steroid use, the program has increased football players’

healthy behaviors and reduced their intentions to 

use steroids.

Until now, anabolic steroids, drugs derived from the 

male hormone testosterone, have rarely been the focus 

of drug abuse prevention studies, says Dr. Ro NemethCoslett of NIDA’s Division of Epidemiology and

Prevention Research.

This may be because steroids are not widely abused. Only

about 2 percent of 8th-, 10th-, and 12th-grade students

have ever used steroids, according to the NIDA-supported

Monitoring the Future study for 1996. However, steroid

abuse occurs more often among young people who are

involved in physical training because anabolic steroids can

increase muscle mass, strength, and stamina, Dr. NemethCoslett points out.

Although adolescent boys, particularly those involved in

athletics such as football or body building, make up the

majority of high school steroid users, national surveys

show that adolescent girls also are vulnerable to the lure of

steroid use. However, that lure contains a hook—anabolic

steroid use can have severe physical and emotional consequences for both males and females. Physical effects can

include stunted growth, high blood pressure, and liver

tumors. Psychological effects can include wide mood

swings that range from episodes of uncontrolled anger and

aggressiveness to clinical depression when steroid use is

Adolescent Girls Abuse Steroids, Too

What do anabolic steroids have in common with amphetamines, tobacco, diet pills, laxatives, and anorectics?

They all are drugs used by adolescent girls seeking to stay thin, says Dr. Linn Goldberg of Oregon Health

Sciences University. The use of these drugs, which often goes hand in hand with eating disorders, is particularly

prominent among adolescent girls engaged in athletic activities ranging from track and field, soccer, basketball,

and volleyball to school dance and drill teams, Dr. Goldberg says. 

Dr. Goldberg and his colleague Dr. Dianne Elliot have been conducting preliminary research, funded by NIDA,

to identify risk factors that influence adolescent girls use of harmful drugs. Among other things, the researchers

have found that many adolescent girls use drugs to maintain thinness, Dr. Goldberg says. National surveys indicate that girls account for about one-third of the high school students who abuse steroids, Dr. Goldberg says.

The primary reason that these girls use steroids is to lose fat and gain lean muscle, he says.

Dr. Elliot and Dr. Goldberg have already developed an effective steroid prevention program for male high school

athletes described beginning on the previous page. Now, they are developing a similar drug abuse prevention

program for adolescent girls. In their future research, the researchers hope to test the effectiveness of the 

intervention in reducing drug use and eating disorders among female athletes in Oregons public middle and

high schools.

Student athletes in the ATLAS

program learn that stunted growth

and many other harmful effects

can result from steroid use.
56

stopped. (See “Questions and Answers About Anabolic

Steroids,” NIDA NOTES, Vol. 12, No. 4)

“The Adolescents Training and Learning to Avoid Steroids

(ATLAS) program uses a team-oriented educational

approach that motivates and empowers student athletes to

make the right choices about steroid use,” says Dr. Linn

Goldberg of Oregon Health Sciences University in

Portland, who led the research team that developed and

tested the program. The program consists of classroom,

weight-training, and parent information components.

Together, they give student athletes the knowledge and

skills to resist steroid use and achieve their athletic goals in

more effective, healthier ways, he says.

In ATLAS’s classroom component, football coaches and

student leaders conduct seven highly interactive sessions

that explore the effects of steroids, the elements of sports

nutrition, and strength-training alternatives to steroid use.

These classes also hone the athletes’ decision-making and

drug-refusal skills. In a typical session, the football team is

split into squads of six or seven students, with student

squad leaders conducting the sessions and teaching most

of the intervention, according to Dr. Goldberg. “It’s kids

talking to kids; that’s an important ingredient in our program,” he says. Coaches, who have a substantial influence

on these student athletes, also play an important role on

the steroid prevention team, Dr. Goldberg says. Coaches

introduce topics and wrap up each session, he explains.

“The ATLAS program is voluntary, and students get no

credit for it, so it better be entertaining,” he says. As a

result, ATLAS classroom sessions are designed to combine

fun and games and learning. Coaches move from squad to

squad and introduce a topic, such as the effects of anabolic steroids. Then squad leaders take over and initiate an

action game that incorporates the topic. For example,

players may toss a football to each other as they answer

questions about problems that stem from steroid use.

“Although they are playing a game, each one is paying

attention and listening because someone is flipping the

ball to them,” says Dr. Goldberg. “No one is saying to

them, ‘Watch out, steroids cause liver disease, acne, and so

forth,’” he notes. “But while they are laughing and having

a good time, they are actually watching and learning at

every step of the way.”

“Football players are athletes; they like to compete,” Dr.

Goldberg notes. Therefore, several games pit squads

against each other to try and earn the most points for 

correct answers about weight training, nutrition, and

steroids. In addition to games, “students do mock public

service announcements, they do ‘rap,’ they do songs, and

they do newspaper articles in the classroom sessions,” 

he says.

In ATLAS’s weight-training component, research staff

members conduct seven hands-on sessions that teach the

students proper weight training techniques. These sessions

are designed to help student athletes build the muscular

strength and agility needed to achieve their athletic goals

without using steroids.

In the parent information component, parents participate

in an information and discussion session about the program with the ATLAS staff. The staff gives the parents a

family sports nutrition guide and encourages them to support and reinforce the antisteroid and nutritional goals of

the program at home. Students in the program say their

parents are more opposed to steroid use after the intervention and often provide healthier meals at home, according

to Dr. Goldberg.

Late last year, Dr. Goldberg reported results of an ongoing

study of ATLAS’s effectiveness in preventing steroid use

among more than 1,500 football players from 31 high

schools in the Portland area. Some 702 football players at

randomly selected schools received the 7-week program

during football season. Another 804 football players at

matched schools served as a control group and received

only a standard informational brochure on the dangers of

steroid use.

Assessments conducted immediately after the intervention

and 1 year later show that, compared with control students, student athletes who participated in the ATLAS

program knew more about exercise, nutrition, and the

harmful effects of anabolic steroids. ATLAS participants

also had an increased sense of personal vulnerability to

negative effects of steroids, more unfavorable attitudes

toward their own and others’ use of steroids, and reduced

intent to use steroids. ATLAS students also showed greater

improvement in their nutritional habits than did control

students. For example, they were more likely to eat highprotein low-fat meals at school, home, and fast-food

restaurants. In addition, ATLAS students were more likely

than students who did not participate in the program to

use established weight-lifting and strength-conditioning

techniques.

“The program’s positive effects flow from changing the

student athletes’ attitudes and perceptions about steroids

and then changing their nutrition and exercise behaviors,”

Dr. Goldberg says. These changes in behavior are reinforced by conducting periodic tests of the athletes’ body

The prevention program gives student

athletes the knowledge and skills to

resist steroid use and achieve their

athletic goals in more effective,

healthier ways.
57

composition, strength,

and power. “If they are

training properly, they

are a heck of a lot

stronger. So, it’s real

positive reinforcement

to them,” he says.

“Student athletes who

participate in the

ATLAS program

achieve,” Dr. Goldberg says. The year before they entered

the program, the football teams that were randomly

assigned to receive the intervention had much worse wonlost records in football than the teams in the control

group had, he says. At the end of the first year, the two

groups’ records were about the same, but teams in the

ATLAS program did slightly better. At the end of the second year, the won-lost records of the ATLAS teams were

substantially better than those of the control teams, with

some of the ATLAS teams making the playoffs at the end

of the season. “I don’t know whether these teams’

improved performance is due to the ATLAS program,”

Dr. Goldberg says. “I do know some of those schools 

hadn’t been to the playoffs in 25 years. The data showing

improvements in program participants’ body composition

and muscle mass are consistent with these teams’ success,”

he says.

Source

• Goldberg, L.; Elliot, D.; Clarke, G.N.; MacKinnon,

D.P.; Moe, E.; Zoref, L.; Green, C.; Wolf, S.L.;

Greffrath, E.; Miller, D.J.; and Lapin, A. Effects of a

multidimensional anabolic steroid prevention intervention: The adolescents training and learning to

avoid steroids (ATLAS) program. JAMA

276(19):1555-1562, 1996.

For More Information 

Oregon Health Sciences University, 3181 S.W. Sam

Jackson Park Rd., CB 615, Portland, OR 97201-3098,

(503) 494-7900. 
Research Findings

58

Specialized High School Prevention Programs Target 

At-Risk Adolescents

By Robert Mathias, NIDA Notes Staff Writer

Volume 12, Number 3 (May/June 1997)

Adolescents on their way to dropping out of school and

abusing drugs can be diverted toward healthier, more successful lives, according to NIDA-supported researchers. 

By using interventions designed specifically to address the

personal and social factors that place some high school

students at risk of drug abuse, schools can reduce these

young people’s drug use and other unhealthy behaviors,

these researchers say. 

One such drug abuse prevention program under way in

the Seattle area has improved academic performance and

reduced drug involvement among high school students

whose poor academic records and behavioral problems

indicate they are at high risk of dropping out of school

and abusing drugs. Another drug abuse prevention program in California is showing promising early results in

reducing and preventing serious drug use among students

in continuation schools. Continuation schools are alternative public schools where students with behavioral and

other problems can complete their high school education. 

Reconnecting Youth

“Our ethnographic studies show that kids who are at high

risk of dropping out of school and abusing drugs are more

isolated and depressed and have more problems with

anger,” says Dr. Leona Eggert of the University of

Washington in Seattle. “They are disconnected from

school and family and are loosely connected with negative

peers,” she says. Additional assessments indicate that many

of these youths also have suicidal behaviors or thoughts,

Dr. Eggert says. Universal drug abuse prevention programs

that are aimed at all youths in a school are usually inadequate to meet the special needs and problems of these

youths, she states. 

Dr. Eggert and her colleagues have developed a high

school-based drug abuse prevention intervention that is

designed for students in the 9th through 12th grades who

are skipping classes, doing poorly academically, and in

danger of dropping out of school and abusing drugs. The

program, called Reconnecting Youth, works to reattach 

at-risk youths to their schools, their families, and positive

peer groups. The program also teaches them social and

personal skills they can use to better manage their emotions and deal with their problems without resorting to

drug use. 

Reconnecting Youth’s core element is a one-semester daily

Personal Growth Class that is incorporated into the

youths’ regular class schedule. The class is led by a teacher

who fosters the development of a mutually supportive

peer group that encourages positive behaviors. The group

encourages acceptance, respect, understanding for others,

and a willingness to help other classmates solve their problems constructively. The class also focuses on enhancing

the youths’ self-esteem; improving their decision-making

and communications skills; and improving their ability to

manage stress, anger, and depression. The ultimate goals

of the program are decreased drug use and increased

school performance and emotional well-being. 

Studies conducted among multiethnic populations of 

at-risk boys and girls in Seattle area high schools show

that, compared to at-risk youths who did not receive the

intervention, youths in the Reconnecting Youth program

have increased academic performance and decreased drug

involvement. The program also improves at-risk youths’

ties to their schools and teachers and increases their selfesteem and social support. The program is equally effective with boys and girls but appears to have more of an

effect on reducing girls’ attachment to friends who skip

school and use drugs. Determining the ramifications of

this apparent gender difference requires more detailed

analysis, which Dr. Eggert plans to do in future studies. 

The latest version of the Reconnecting Youth program

includes additional classroom and school components 

that address the needs of the substantial portion of these

youths who also are at risk for suicide. The program has

been shown to decrease depression, anger and aggression,

stress, and suicidal thoughts and behaviors among these

youths. 

Project Toward No Drug Abuse

Adolescents completing their education in continuation or

alternative public high schools are another group at high

risk for drug abuse. In California, youths are transferred

from regular schools to continuation high schools because

of negative behaviors such as drug use, truancy, and fighting with schoolmates, explains Dr. Steven Sussman of the

University of Southern California. These students report

much higher levels of drug and alcohol use than do students in traditional schools, he says. Research by 
59

Dr. Sussman and others indicates that about 36 percent of

continuation high school students report weekly marijuana use compared to 9 percent of high school students in

traditional schools. About 25 percent of continuation high

school students in California also say they smoke marijuana daily, Dr. Sussman says. 

Preventing drug abuse among these youths presents many

difficulties, he says. First, drug abuse prevention programs

that have worked with general populations of younger

adolescents in junior high and middle school are less likely

to be effective with these older, at-risk high school students. Second, students in continuation high schools present a complex mix of behavioral and social problems and

come into daily contact with many other students who

use drugs and have a favorable attitude toward drug use.

Finally, many of these youths already have used, or currently are using, a variety of drugs. 

To meet the needs of this at-risk population, Dr. Sussman

has been developing a specialized school-based curriculum

for continuation high school youths that forms the core of

a program called Project Toward No Drug Abuse. To

develop the curriculum, he relied heavily on extensive testing and the feedback of continuation high school youths

themselves. This research sought to ensure that the curriculum would be acceptable and relevant to these youths,

tailored to counteract their specific reasons for drug use,

and practical for continuation high schools to implement. 

The resulting curriculum consists of motivational activities, social skills training, and decision-making components. These components are delivered in nine classroom

sessions over the course of three weeks to all students in

the continuation high school by health educators trained

by project staff. The program uses a variety of interactive

teaching strategies such as role playing and self-scoring

questionnaires to motivate students in the class against

drug use, provide them with the skills they need to change

their negative behaviors, and guide them toward decisions

to not use drugs. 

“What we’re doing in the nine lessons is trying to find

motivators for change that are personally relevant for these

high-risk youths,” says Dr. Sussman. For example, in one

session, the students are encouraged to resist succumbing

to negative stereotypes of continuation high school students as “losers” who abuse drugs and have no goals in

life. In fact, continuation high school students say they

have goals like anyone else, such as getting a job or

attending college, Dr. Sussman says. Therefore, another

session demonstrates how drug abuse can destroy their

health and limit their ability to achieve their goals.

“Basically, we are getting them to be more internally and

externally consistent so their behavior matches what they

think of themselves and what they want,” he says. 

The curriculum for Project Toward No Drugs is currently

being tested among a multiethnic group of more than

1,500 boys and girls in 21 continuation high schools in

southern California. An initial analysis conducted 1 year

after the conclusion of the class indicates that the program

has had significant preventive effects on drug and alcohol

use, Dr. Sussman reports. Because the program was developed with feedback from boys and girls from a number of

ethnic groups, there were no significant differences in

effect by gender or ethnicity, he says. 

Sources 

• Eggert, L.L. Psychosocial approaches in prevention

science: Facing the challenge with high-risk youth.

Communicating Nursing Research 29(4):73-85, 1996. 

• Eggert, L.L.; Nicholas, L.J.; and Owen, L.M.

Reconnecting Youth: A peer group approach to building

life skills. Bloomington, IN: National Educational

Service, 1995. 

• Eggert, L.L.; Thompson, E.A.; Herting, J.R.; and

Nicholas, L.J. Reducing suicide potential among

high-risk youth: Tests of a school-based prevention

program. Suicide and Life-Threatening Behavior

25(2):276-296, 1995. 

• Eggert, L.L.; Thompson, E.A.; Herting, J.R.;

Nicholas, L.J.; and Dicker, B.G. Preventing adolescent drug abuse and high school dropout through an

intensive school-based social network development

program. American Journal of Health Promotion

8(3):202-215, 1994. 

• Sussman, S. Development of a school-based drug

abuse prevention curriculum for high-risk youths.

Journal of Psychoactive Drugs 28(2):169-182, 1996. 

• Sussman, S.; Simon, T.R.; Dent, C.W.; Stacy, A.W.;

Galaif, E.R.; Moss, M.A.; Craig, S.; and Johnson,

C.A. Immediate impact of thirty-two drug abuse prevention activities among students at continuation

high schools. Substance Use and Misuse 32(3):265-

281, 1997. 

For more information

• About Reconnecting Youth, contact Psychosocial and

Community Health Department, Box 357263,

University of Washington School of Nursing, Seattle,

WA 98195-7263, (206) 543-9455. 

• About Project Toward No Drug Abuse, contact

Institute for Health Promotion and Disease

Prevention Research, University of Southern

California, 1540 Alcazar St., CHP 207, Los Angeles,

CA 90033, (213) 342-2589. 
Research Findings

60

Multifaceted Prevention Programs Reach At-Risk Children Through

Their Families

By June R. Wyman, NIDA NOTES Staff Writer

Volume 12, Number 3 (May/June 1997)

Two NIDA-funded studies are finding that working with

the family is more effective in reducing risks of drug abuse

than working with parents or children alone. Both projects target families at risk. The Strengthening Families

Program works with parents and children in families

where the parents abuse drugs, while Focus on Families

works with parents who are in methadone treatment.

Children from such families, research shows, are at risk for

becoming drug abusers themselves. 

Strengthening Families

The Strengthening Families Program is aimed at 6- to 10-

year-old children of drug abusers and their parents. 

“We work on improving parent-child relationships—their

time together, their communication patterns,” says Dr.

Karol Kumpfer of the University of Utah in Salt Lake

City, the project’s principal investigator. “We try to change

the family dynamics, to create a more democratic family

where they actually have family meetings, talk together,

and plan activities together. Then the child feels that he 

or she belongs to something, that ‘we are a family, we

believe certain things, we stand for certain things, and 

we work together as a unit.’” 

Dr. Kumpfer devised her program after reviewing more

than 500 family drug abuse prevention programs. From

this survey, she designed a study to compare three promising approaches: a 14-session parent training program; the

same program combined with a children’s skills training

program; and a three-way merger of the parent and child

programs with a family skills training program. 

Her study, done in Salt Lake City, involved families with

parents who were in methadone treatment programs or

who were substance-abusing outpatients at community

mental health centers. The research showed that the threepart intervention was the most powerful in reducing problem behaviors. Compared with families that did not

receive any intervention, families that went through the

three-part program showed significant improvements in

adults’ parenting skills, children’s social skills, and family

relationships. Children achieved significant reductions in

aggressiveness and other problem behaviors. Older children significantly reduced their use of tobacco, drugs, and

alcohol, and parents reduced their depression and drug

use substantially.

The three-part curriculum became the Strengthening

Families Program and has since been adapted and tested

with different ethnic populations across the country.

Although these modified versions of the program differ in

cultural content, all use the same basic framework: parent

training, children’s training, and family skills training. In

each of 14 weekly sessions, groups of parents and children

Defining Prevention Programs By Their Audiences

Any program works best when it is tailored to its audience—and the same is true of drug abuse prevention efforts.

While some programs try to reach whole communities, others target specific at-risk subgroups. To describe the

different approaches, researchers have adopted new definitions:

• Universal programs reach the general population, but in a defined setting. Example: all students in a school. 

• Selective programs target groups within the general population that research has defined as at risk for drug

abuse. Examples: children of drug abusers, poor school achievers. 

• Indicated programs are designed for people who already have tried drugs or show other risk-related problem

behaviors. Example: high school students at risk for dropping out because of multiple problems such as

depression, poor grades, and substance abuse. 

A project may use one, two, or all of these strategies. The family-focused programs on this page are selective 

prevention projects; the school-based programs described in “Specialized High School Prevention Programs Target

At-Risk Adolescents” (page 60) are indicated programs. 
61

are taught separately for the first hour. In the second hour,

they come together to practice their new skills. Afterward,

the whole group shares dinner and a movie or other entertainment. 

In their sessions, children learn how to be direct, to talk

about problems, and to ask for what they need. For example, “A lot of the kids say that they would like to tell their

parents to stop using drugs, and they just don’t know how

—so we teach them those skills,” says Donna Lee Picaso, a

caseworker with the Denver Area Youth Services Agency

who led children’s classes in the Denver study. Children

also learn how to resist peer pressure, handle anger, deal

with criticism, and cope with problems without resorting

to drugs. 

Parents are trained in techniques such as establishing

goals, giving incentives and reinforcements, and setting

limits. “They’re right up front with saying they have very

limited skills, and they’re anxious to learn new ones,” says

Donna Martinez, a social worker in the Denver study. 

Sessions are held in facilities that are easy for participants

to reach such as family support centers in urban housing

projects, community centers, local churches, and schools.

Group size has ranged from 5 to 14 families. Session leaders are recruited from local social service agencies and have

counseling or social work experience. 

Focus on Families

A different approach is taken in Focus on Families, a parenting program for methadone treatment patients developed by Dr. Richard Catalano and his colleagues at the

University of Washington in Seattle. The goal of this program is to reduce parents’ use of illegal drugs by teaching

them how to cope with problems without resorting to

drug abuse and how to manage their families better. 

The program was tested in Seattle with families recruited

from two Seattle-area methadone clinics. Although all parents were in methadone treatment to reduce their drug

use, 54 percent reported that they had used heroin, marijuana, cocaine, and other illegal drugs in the month before

entering the family program. Families were randomly

assigned to the experimental group, which went through

the Focus on Families program, or the control group,

which did not. 

After families attended an initial 5-hour retreat, parents

completed 4 months of twice weekly 90-minute training

sessions. Children attended 12 of the sessions to practice

communication skills with their parents. 

Case managers visited each family at home every week for

9 months to help apply new skills and solve family problems. These house calls were critical, says Kevin Haggerty

of Dr. Catalano’s research team. “Families need hands-on

coaching to reinforce the skills they learn and to deal with

the never-ending crises in the lives of addicted parents.” 

To assess the program’s impact, parents were interviewed

before the program, right after their 4-month training,

and again at 6, 12, and 24 months after the end of training. Children age 6 and older in the treatment families, as

well as control group families, were interviewed at the

same intervals. 

At the 12-month interview, program parents reported 

dramatic reductions in their heroin and cocaine use and

significantly better parenting skills compared with the

control group, Dr. Catalano reports. At the 24-month 

followup, parenting and problem-solving skills remained

significantly better, but “we lost the significant treatment

effects on drug use,” says Haggerty. “Family interventions

need to be ongoing with parents who are drug addicts,” 

he concludes. 

Average Drug Use During Past 30 Days By Parents, 

12 Months After Finishing Focus on Families Program

Parents in the Focus on Families parenting program, all

recruited from methadone treatment clinics, reported using

heroin and cocaine less often than did clinic parents who did

not participate in Focus on Families.

“A lot of the kids say that they would

like to tell their parents to stop using

drugs, and they just don’t know

how—so we teach them those skills.”
62

The program had a mixed impact on the children, who

ranged in age from 3 to 14 years. At the 24-month followup, program children reported a trend toward less

delinquent behavior and marijuana use, and those 9 years

and older reported lower rates of alcohol initiation. The

program appears to have had a greater impact on younger

children than older ones. This finding suggests that 

children of addicts may benefit more if they are exposed

to improved parenting earlier and longer, the researchers

conclude. 

Next Steps

Despite promising results from these models, there is

much to learn about preventing drug abuse in families,

says Dr. Rebecca Ashery of NIDA’s Prevention Research

Branch. More research is needed on issues such as: 

• how to adapt successful programs to different cultural

and ethnic groups as was done with the Strengthening

Families Program; 

• how males and females respond differently to drug

abuse prevention training; 

• how to attract and retain families in prevention 

studies; 

• intervening with the extended family; and 

• intervening with the most dysfunctional families—for

example, parents who take drugs, are physically or

emotionally abusive, and suffer from major mental 

illnesses. 

Another next step is to put more emphasis on very young

children. “Through research we’re finding out that it’s not

too soon to intervene early in school or even before

school,” says Dr. Ashery. 

“In the long run, what it will take is a comprehensive

approach. You can’t do the family in isolation, the school

in isolation, the community in isolation,” she says. “You

have to do it all in concert: school, family, and community together.” 

Sources 

• Catalano, R.F.; Haggerty, K.P.; Fleming, C.B.; and

Brewer, D.D. Focus on Families: Scientific findings

from family prevention intervention research. NIDA

Research Monograph, in press. 

• Kumpfer, K.L.; Molgaard, V.; and Spoth, R. The

“Strengthening Families Program” for the prevention

of delinquency and drug use. In: Peters, R., and

McMahon, R., eds. Preventing Childhood Disorders,

Substance Abuse, and Delinquency. Thousand Oaks,

CA: Sage Publications, pp. 241-267, 1996. 

For more information:

• About the Strengthening Families Program, contact

Dr. Karol Kumpfer, Department of Health

Education, University of Utah, Salt Lake City, UT

84112, (801) 581-7718. 

• About Focus on Families, contact Kevin Haggerty,

Social Development Research Group, University of

Washington, 9725 Third Ave. N.E., Ste. 401, Seattle,

WA 98115, (206) 543-3188. 
Research Findings

63

Research Meets the Challenge of Preventing Drug Use Among

Young People

By NIDA Director Dr. Alan I. Leshner

Volume 12, Number 3 (May/June 1997)

National surveys of drug abuse have brought

disturbing news in the last few years: Drug use

has increased among our Nation’s youth.

While some news media speculate about a

possible return to the high levels of adolescent

drug use that the Nation witnessed in the

1970s, they are missing an equally important

and more hopeful story. NIDA-supported 

prevention research has made great strides 

in developing both the knowledge and the

tools that can stem the tide of drug abuse 

and curb its devastating effects on our Nation’s

young people. 

A growing body of scientific information shows that many factors can

protect young people from drug use

while other factors put them at risk

of abusing drugs. Strong parent-child

attachment, appropriate parental

supervision, commitment to school,

academic success, and friends who

have conventional values are some

protective factors. Chaotic family

environments, ineffective parenting,

poor academic performance, and deviant peer influences

all put youths at risk. We also know that the impact of

specific risk and protective factors may diminish or increase

as young people develop, and their circumstances change.

Because risk and protective factors for drug use are found

in the home, the school, and the community, NIDA has

supported research on prevention programs in each of

these domains. As a result, prevention practitioners now

can select from a broad array of effective family-, school-,

and community-based prevention programs to meet the

needs of different groups in their communities. 

Successful drug abuse prevention programs fall into three

categories—universal, selective, and indicated—that

describe their intended audience. “Universal” programs are

meant for everyone in a school, a community, or a similar

group and can reduce the overall prevalence of drug use.

Our research indicates that universal community programs

need to be comprehensive with well-coordinated components for the individual, the family, the school,the media,

and community organizations. One such universal 

community-based program, developed by

NIDA-funded researchers at the University

of Southern California in Los Angeles, has

reduced drug use over a 5-year period

among middle-school students in Kansas

City, Missouri. In this comprehensive program, a classroom curriculum teaches students how to resist influences to use drugs.

In addition, schools, parents, mass media,

and community organizations work

together to promote consistent antidrug

messages, attitudes, and policies in 

the community.

Although universal drug abuse

prevention programs can work

with general populations, they

may not meet the special needs

of groups within those larger

populations who are particularly

at risk of drug abuse. NIDAfunded researchers have been

identifying these at-risk groups

and individuals and developing

“selective” and “indicated” programs to meet their complex needs. A special section in

this issue, “Children on the Brink: Youths at Risk of Drug

Abuse,” highlights some of the remarkable results of this

research. 

“Selective” drug abuse prevention programs target groups

who are exposed to factors that place them at greaterthan-average risk of future drug abuse. Such programs are

tailored to reduce the identified risk factors and strengthen

appropriate protective factors in these individuals’ lives.

Research shows that children of substance abusers make

up one such at-risk group.

Armed with this knowledge, NIDA-supported researchers

at the University of Utah in Salt Lake City have developed

a selective prevention program for these children and their

parents. The family-focused program works to improve

interactions within families. As a result, the program has

reduced family conflicts, youth problem behaviors such 

as aggression and delinquency, and substance abuse. 

(See page 62, “Multifaceted Prevention Programs Reach

At-Risk Children Through Their Families.”) 

Prevention practitioners now

can select from a broad array

of effective family-, school-,

and community-based 

prevention programs. 
64

NIDA also has supported research to develop “indicated”

drug abuse prevention programs for adolescents who

already are exhibiting early signs of drug abuse and other

problem behaviors such as school failure, antisocial behaviors, and psychological problems. Research shows that

youths with these characteristics are at high risk of continued drug abuse. Successful indicated programs address

these youths’ specific problems, enhance protective factors,

and reduce their substance use. A high school-based indicated program developed for such troubled youths by

NIDA-supported researchers at the University of

Washington in Seattle has reduced their problem behaviors, increased their academic performance, and reduced

their drug involvement. (See page 60, “Specialized High

School Prevention Programs Target At-Risk Adolescents.”) 

While NIDA research shows that drug abuse prevention

can work, we need to expand the range of effective prevention approaches and strategies. In one such effort,

NIDA’s Division of Epidemiology and Prevention

Research is emphasizing the development of family prevention programs that intervene in early childhood to

improve family functioning and parenting skills. Such

early childhood programs could reduce risk factors and

build resistance to drug use even before children enter

school. Current studies also are testing new school-based

programs that begin as early as kindergarten and extend

through the primary grades. Several of these programs are

aimed at children with conduct disorders, a known risk

factor for later drug abuse. 

We also are seeking and supporting research on the special

needs of older children and adolescents who have dropped

out of school, run away from home, become homeless, or

been placed in juvenile court detention programs. This

comprehensive research program will help us develop targeted interventions to meet the specific needs of diverse

groups of youths at risk of drug abuse. (See “Drug Abuse

Among Runaway and Homeless Youths Calls for Focused

Outreach Solutions,” NIDA NOTES, Vol. 12, No. 3) 

The increased drug use we have seen among America’s

youth in recent years is a warning signal that it is time for

new and effective solutions to address the problem.

NIDA’s prevention research program is providing the

knowledge, guidance, and tools to States, communities,

families, and individuals as they work to ensure that

young people remain firmly on the road to healthy and

productive lives. 

Early childhood programs could

reduce risk factors and build 

resistance to drug use even before

children enter school. 
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Revised April 2008

Revised September 2006

Printed September 2002