Tuesday, January 1, 2013

Drug Abuse Resistance Education (D.A.R.E.): An evaluation of program efficacy based on social science theory and available alternatives--Ashley Thomas

Introduction: The Drug Abuse Resistance Education (D.A.R.E.) Program
I remember when he first came into our classroom. He was very tall, neatly dressed, and very austere (I didn’t know that word at the time, but it perfectly encapsulates his demeanor). Then again, as a fifth-grader, everyone is very tall, anyone in uniform always appears neatly dressed, and all adults are austere. He quietly sat in the back of the room until our teacher, Mrs. English, introduced him. Despite how vivid all of his physical characteristics and mannerisms still are, I cannot remember his name, so for our purposes, we’ll refer to him as Officer Joe. Officer Joe was a trained officer of the Drug Abuse Resistance Education (D.A.R.E.) in-school program, and our classroom was his “beat” for the next few weeks.
Developed in 1983, D.A.R.E. is an in-school curriculum that addresses pressures placed on youth regarding drug use and violence (1). It has since expanded from its original home of Los Angeles to around 80% of United States school districts and 43 countries worldwide (1). Intrinsic to the program, making it unique among other in-school drug resistance education programs, is the incorporation of local law-enforcement personnel (2). Over a series of 16 weekly lessons, the officer charged with educating the students introduces facts about drug use (both underage and otherwise) and violence, while giving the students tools and strategies to employ later on should they be confronted with a, “…high-risk, low-gain choice…” (3)(4). At the program’s culmination, lesson 17, participating students will reflect upon what they have learned and what they hope to carry with them going forward.
The D.A.R.E. program was borne out of Nancy Reagan’s directive to children to, “Just say no!” to drugs and alcohol (5). Despite its current ubiquity, the D.A.R.E. program has been the target of many analyses and criticisms decrying its efficacy. In some cases, it achieves no measurable effect, certainly not enough to warrant the resources necessary for its implementation. While the program has, admirably, evolved significantly in response to these evidence based evaluations, understanding past failed strategies will be integral to creating new, more effective curricula.
In context, as of 2010 (most recently available data), drug and alcohol usage rates among teens and young adults climbed compared to past years. Among youth aged 12-17, the rate of illicit drug use was about 10% and about 7% reported currently using marijuana. The data is much starker when looking at alcohol: 29% of those surveyed reported being current users. Within this category, 25% of those aged 12-17 reported current use, and nearly 50% of those aged 18-20 reported current use in the past month (6). As was demonstrated not only by multiple meta-analyses, but also by the persistence of drug and alcohol use among minors, D.A.R.E. fails to resonate with the students for whom the program is tailored. This failure comes at high cost to the school, the state, and the federal government (7)(8).
This analysis will take a hard look at three specific aspects of the program model and question the social sciences theories from which those elements were derived. The model of the program is predicated on the assumption that, regardless of the situation or background of the student, he or she will be able to reason through a decision relating to drugs, alcohol, or violence. Many of the weaknesses of the earliest iterations of the program were a result of this intense focus on individual linear reasoned behavior. New curricula and lessons still fail to consider the environment in which the student is raised and the modeling that impacts their ultimate choice. Compounding this issue is the fundamental flaw of the program in addressing the normalizing of risky behavior in youth. While “peer pressure” is a focus of the program model, its interpretation within the model is dated and often not applicable to real-world circumstances. Finally, the program assumes that by injecting the students with a bolstered sense of self-esteem, environmental and situational influences will no longer be relevant. Unfortunately, youth and their social situations are much more complex than that.
I.               Criticism of the D.A.R.E. model
A.    Critique 1: What works for one should work for all
In its earliest versions, D.A.R.E. targeted fifth- and sixth-grade students. The goal was to intervene as early as possible to equip students as quickly as possible for any challenges they may face regarding drug or alcohol use, or violence. Even though the program was created for an extremely racially and socioeconomically diverse student population (9), the program takes a homogenous approach to all students, regardless of background.
Simply due to the sheer volume of students exposed to this program regularly, it is unrealistic to assume that all students receive the program in the same way. Based on the social learning theory, some behaviors have likely already been modeled and normalized in the home. While these are not the behaviors targeted by the program, the efficacy of the program is questionable if the students already have a mental construct of the impact of drugs and violence in the home. This mental construct can be healthy or dangerous, but the structure of the D.A.R.E. program does not account for either. The implicit conclusion that follows from the D.A.R.E. model is that any drug or alcohol use should be absolutely avoided. These rigid social norms will conflict with the modeling to which the student has already been exposed, and the desired effect of imparting a zero-tolerance mentality on the student is not just diluted, but also eventually lost (given the brief nature of the program).
In 2001, the National Highway Traffic Safety Administration (NHTSA) released a comprehensive set of “How To” guides around the topic of underage drinking prevention. In it, they mentioned that there are a number of risk factors that are reliable indicators of a student’s likelihood to abuse alcohol underage. These include the following: parental drug use, family structure and function problems, lack of commitment to school, anti-social behavior, and biological predisposition (10). With these in mind, the student who can most benefit from the message given by D.A.R.E. is least likely to engage with the program because she is not in school, nor would it be her first (or most formative) encounter with drug and alcohol use. Because of the program’s structure, however, these differential risks within the student population are masked and unattended. Even if family or friends have not exposed students to any sort of drug culture, they certainly encounter print, media, or Internet advertisements, and each student to varying degrees. Admittedly, singling out students who are at greater risk is not a favorable alternative, but the D.A.R.E. model presumes a homogeneity among students that does not, in fact, exist. If it did, the model would be singularly effective in any setting with any permutation of student representation, including those who’d already tried drugs or alcohol prior to participating in the program.
D.A.R.E.’s disregard for social and environmental pressures is indicative of its baseline belief in the capacity of the individual student to reasonably make a decision regardless of the situational constraints or past experiences. This stringent adherence to the individual level social science model (particularly the Theory of Planned Behavior) is effective in perpetuating the mission of the program but does not successfully equip students and youth with the tools necessary to confront complex situations involving friends and social pressures to conform.
B.    Critique 2: Fitting in is of no concern
In focusing so heavily on the individual agency of the student, the D.A.R.E. model does not effectively confront the realities of tenuous social situations, especially those encountered in groups. D.A.R.E. struggles to address peer pressure, but it does so in ways that neglect the very basic principles of herd behavior and social organization theory. Students are taught strategies and methods to, “Just say no!” but those strategies do not take into account the pressure of group behavior and perceived social roles.
The D.A.R.E curriculum prescribes very vague and general steps towards confronting peer pressure. In their model, they help students to identify characteristics of positive and healthy friendships and encourage them to build social and support networks buttressed by these relationships (3). The difficulty, however, is translating these skills to new environments with new and different potential friends and navigating potentially risky situations while in these novel surroundings.
The herd mentality theory asserts that individual choice is heavily, often imperceptibly, impacted by perceptions of behavior within the same peer group. In this scenario, a young underage student, most likely in high school or early college, attends a party where alcohol is being consumed. She leaves for the party armed with her fifth-grade D.A.R.E. training, but upon encountering a group of like individuals who are drinking, she is more likely to forget Officer Joe and instead join her peers. Thaler and Sunstein document behavioral changes like this not only in underage drinking, but in eating habits, voting patterns, and tax compliance (11). They point out that the notion of “acceptable” or “normal” behavior may, in fact, be based on false information, but the reality is that the group will behave in accordance with the prevailing assumptions. In this case, the prevailing assumption is, when you attend a party, you drink alcohol. What is at play here is an intense desire to conform. If the long-term consequences, however grave or benign, are not frighteningly obvious, conformity to immediate group behavior is inevitable and well documented. This is an insidious form of peer pressure for which the D.A.R.E. model does not account. Its earlier models were actually chastised for hyperbolizing the ever-present threat of drugs and alcohol, counter-intuitively normalizing a behavior that they were trying to stop.
Behaving in accordance with the peer group is not to say that all agency has been stripped from the individual. On the contrary, according to social organization theory, there is an implicit understanding within a group that each individual has a role to play and rules to play by to maintain the order of the social structure (12). As our student example from above is likely the newest member to the social hierarchy, her desire to conform is driven by deeply held socialization that differentiation is the enemy of assimilation. Coupled with her understanding of the rules, as they are manifest by the other, more senior, members of the group, she adheres to the norms established prior to her introduction. If she doesn’t, she runs the risk of being ostracized simply because other members of the group will no longer be able to play by the same set of rules in approaching her as they would if approaching anyone else.
D.A.R.E. scratches the surface of the pressure encountered by young adults on daily basis when confronted with risky decisions. It does not, however, incorporate the pressures of making decisions, as a new actor, within the confines of a group with either limited knowledge or well-earned knowledge. In that scenario, the actor is faced with the seemingly more important decision to either fit in or get out, despite her level self-confidence prior to entering the party.
C.   Critique 3: Self-efficacy will save us all, or at least the children
D.A.R.E. proponents vehemently believe in the Theory of Planned Behavior. The current model is built around the notion that improving a student’s sense of self-efficacy will ultimately empower the student to make the best decision in a high-risk situation, regardless of surroundings. If this is true, then all of the weaknesses noted above are immaterial because the more confident the student is, the less external social and environmental constructs and group behavior will matter. The fatal flaw of this model, however, is the assumption that an agent will always behave rationally.
A hallmark and critical success of the D.A.R.E. model is the focus on the self-esteem of the students. Noted in the same NHTSA guidelines, two additional warning signs for early drug and alcohol abuse are: low self-esteem and shy temperament at a young age (10). This programmatic strength is, unfortunately, only a proximal result of the model: the students reported feeling a bolstered sense of self only immediately after the program’s conclusion (2). If this is a method to counter the impact of the externalities of environment and group behavior, it is ineffective.
This focus appears to be the model’s participation in the transition from the Theory of Reasoned Action (TRA) to the Theory of Planned Behavior (TRB). Past studies have tried to show that the TRB is a somewhat reliable predictor in the underage use of alcohol, as long as the most compelling factors (e.g. attitude toward alcohol, subjective norms, and prerequisite intention to use) align correctly (13). The researchers firmly asserted that as long as a young adult intended to use alcohol, and all of the other social and personal factors were met, he or she would, indeed use alcohol. Perhaps, then, if the students were taught to no longer intend to use alcohol, the risk would be eliminated.
Unfortunately, what the TRB does not take into account are changes to those critical factors that influence intention, while assuming a strictly linear movement from assessment to intent to action (14). Does this theory hold in the context of our party example from earlier? Does the new student have the time and opportunity to weigh her parents’ opinions, her siblings’ opinions, and her friends’ opinions in a moment after she is asked whether or not she would like a drink? Likely not. D.A.R.E.’s vision to empower the participating students to take greater stock in themselves and have faith in their own self-worth is absolutely essential for healthy development. However, as a means of addressing the rather amorphous concept of “self-efficacy” in an effort to impact a nice, but unrealistic, decision-making model, it is idealistic and poses no real lasting beneficial effect for the students.

II.             Proposed Improvement: Every 15 Minutes and Mariah’s Challenge
As vividly as I remember Officer Joe, I remember a day in May when I was in eighth grade. I had just come home from school and I noticed a newspaper article with my older brother’s photo. The headline read, “High School Junior Dies in Tragic Drunk Driving Accident.” The article talked about all of his achievements, how bereaved our family was, and what a shame it was to have lost him that way. I was confused. While I was reading the article, my brother came bounding in to the kitchen and grabbed a snack from the refrigerator. It was safe to say I had no idea what was going on. I came to find out that my brother was part of the Every 15 Minutes program at his high school.
Every 15 Minutes was developed around the statistic that every fifteen minutes, someone was killed in a drunk driving accident. While this statistic is now dated, and drunken driving fatalities have decreased by more than 50%, underage drinking and driving is still a reality. The CDC reported that in 2011, nearly one million high school aged youth drank and decided to drive (15). Clearly there is still a disconnect in the message being communicated by anti-drug programs and the actual behavior of teens and young adults.
The D.A.R.E. program, in an effort to be comprehensive, attempts to educate students on the dangers of multiple drugs and violent acts. Because the program is limited to 16 lessons, the practitioners cannot delve deeply into specifics about a given drug. These recommendations will focus on adolescent drinking and risky behavior associated with the decision to drink. Here we will critically look at two interventions that successfully use social science models to strengthen and brand community of non-alcohol users: Every 15 Minutes and the Mariah Challenge. An effective intervention targeting underage drinking and risky behavior will combine the key elements of both of these programs and will reach more students and resonate more deeply.
A.    Response to Critique 1: Creation of a new community through shared experience
The Every 15 Minutes campaign is a multi-faceted program incorporating various media to bring the reality of drunk driving directly to a student population through simulation. Students from the school will be selected to participate in a mock car collision, where some will play the victims (both injured and dead) and others will play the perpetrators. The simulated accident will take place on the school grounds, and the car (often a car that was actually involved in a drunk driving accident) will remain on the campus for a specified period of time. Those who have “died” will have obituaries written for them, and the school will hold a memorial assembly in those students’ honors. Parents will be notified of the students’ “deaths” and both students and parents will participate in a letter-writing exercise expressing their feelings surrounding the incident. After the “accident” and prior to the memorial assembly, students involved in the “accident” will be taken off campus to participate in a one evening retreat led by local law enforcement officers and counselors, while their classmates are instructed to reflect on the accident witnessed. Individual schools can choose to incorporate or subtract specific elements from the experience, but overall, the program is the same across schools (16).
The brilliance of this intervention lies in its novelty. No matter what the background or former experiences are of the students participating, the entire community together witnesses and works through a tragic accident. This group-level intervention incorporates multiple members of the community, and serves as a unifying event within the school populations’ collective history. If the school chooses to adopt this same intervention annually, the tragedy is not lost on those who have previously experienced it as different students are selected to participate each year. In contrast to the D.A.R.E. one-size-fits-all model, Every 15 Minutes simulates a difficult and tragic event around which an entire community rallies, effectively and lastingly reaching more students than the D.A.R.E. model structurally could.
Emotional and resonant in nature, Every 15 minutes also capitalizes on one recognized strength for addressing underage drinking through school programming: interaction (17). In this intervention, the students are the very center of the appeal and those who are targeted are the students as well. This dramatization exemplifies the central piece of the communications theory, as the victims of this simulation are those with whom fellow students can identify the most. While the simulation initially is not positive in nature, the reintroduction of the students back into the school population brings a sense of relief. After forcing the students to confront the realities of losing a classmate either to arrest, injury, or death by reckless decision making, that relief is much more profound and persistent over time.
B.    Response to Critique 2: Branding a community of non-users
A sense of relief is a feeling that Leo McCarthy has been trying to regain for the last five years. In 2007, his 14-year-old daughter was struck and killed by an underage drunk driver. While giving his daughter’s eulogy, McCarthy made a commitment to provide scholarships to high school students who pledged not to drink until they are 21, not to get into a car with someone who’d been drinking, and to give back to their communities. The pledge can be taken and signed online and as long as a student has not been convicted of any underage possession related offenses, the student is eligible to receive at $1,000 scholarship upon graduation (18).
Mariah’s Challenge is a grass-roots organization that is built on the fifth premise of alternative social science models, and creates a sense of premature ownership in the students who decide to take the pledge. By incentivizing students with the a potential scholarship, McCarthy is forcing the students to commit to a behavior based on an anticipated, but not guaranteed, pay-off without having to buy into the principles or dogmas that would otherwise lead to the desired behavior change. As the students get closer to graduation, the likelihood of winning the $1,000 scholarship is greater and greater and, based on the theories of ownership, the students are more likely to adhere to the pledge regardless of external pressures.
The intriguing facet about this intervention is that it also builds a branded community. In the way that the popular Livestrong campaign has merchandise and identifiable imagery, Mariah’s Challenge has a very recognizable logo and associated pink merchandise that is quickly and easily linked to the cause. In creating this brand, McCarthy has also created a community of inclusion for the students who choose to pledge. Regardless of where those students go, or with whom they interact, they will always be a part of Mariah’s Challenge. With that brand comes the promise of responsibility. Being armed with that is much more potent in the face of making difficult choices than being taught strategies to deal with one-on-one peer pressure, as the D.A.R.E. model would advocate. A member of this Challenge community will always be a member as long as he or she follows through on his or her pledge. Because it is reinforced in a comfortable setting at first, it is something that can transcend the pressure introduced by novel surroundings, new individuals, or a changed culture of acceptance.
C.   Response to Critique 3: Changing social norms
Both the Every 15 Minutes intervention and the Mariah Challenge are working to change the social norms surrounding underage drinking and driving by approaching the community most affected. It was not until recently that the D.A.R.E. program expanded to include high schools. By the time the graduates of the early D.A.R.E. elementary programs reached high school, the value of the program, if any gained at all, diminished. One could thus surmise that any lessons learned were either forgotten or drowned out by other social pressures, personal experiences, or environmental stressors.
By the time early graduates of the D.A.R.E. program reach high school, they are no longer in control of the social norms surrounding drinking culture. They are subject to them. Interventions like Every 15 Minutes and Mariah’s Challenge are forcing high school students to question two assumptions: that it is permissible to drink underage and that driving after drinking is not a serious offense. Every 15 Minutes combines the gruesome reality of drunk driving accidents with the profound emotional impact of losing a loved one to such a horrific incident. It makes tangible the otherwise easily written off threat that drinking and driving poses. Mariah’s Challenge, borne out of such a tragedy, mobilizes a community of committed students to take ownership of their futures. In doing so, they will first change their behaviors, later change their attitudes, and even further down the line, impact others to do the same. These collective changes serve to impact the culture of drinking in the high school environment by changing the subjective norms on the group level.
Changing the subjective norms, particularly those of immediate peers, surrounding the decision or intention to drink while underage would render the Theory of Planned Behavior moot. At the point where norms are changed, the issue of self-efficacy is no longer relevant. Three independent studies evaluating effective strategies for mitigating underage alcohol consumption have all recommended that a concerted effort be placed on changing the societal and community norms surrounding drinking (19)(17)(10). D.A.R.E.’s insistence on the use of individually focused social science models, particularly the TPB, just speaks to its own inability to adapt and evolve in time with the populations they are most trying to impact.
III.           Conclusion
The United States Surgeon General has issued a comprehensive, multi-tiered plan to address the persistent problem of underage drinking (20). She, a newly appointed official, taking such a bold step towards combating this issue is indication enough that current programming has not been working. One of the most ineffective of all of these currently existing is the Drug Abuse Resistance Education program. It is built using individually focused social science theories and fails to take into consideration the pressures of group behaviors and environmental pressures into its model, and the only group suffering are those for whom it was initially intended.
In its wake, other interventions have arisen to address D.A.R.E.’s shortcomings. Programs like Every 15 Minutes and Mariah’s Challenge have built communities around shared experiences and have branded young students as ambassadors of responsibility, imbuing them with a sense of purpose that transcends peer and social pressures. A program with the brand power and sense of ownership of Mariah’s Challenge coupled with the powerful community building effect of Every 15 Minutes could elicit significant change among high school students and young adults. These programs are specialized to target very specific drug related behaviors, compared to D.A.R.E.’s comprehensive, all-encompassing approach, and create a profound and lasting impression on those who participate, adults and students alike.
CNN recently reported on a young woman who lost her father and older brother to a drunk driver in one evening. She has since become an advocate against the behavior and has told her story to multiple audiences. What she’s realized is that her story is much more powerful than any numbers or fact sheets, and she has committed to continue telling her story as long as it proves beneficial to anyone somewhere (21). I don’t remember Officer Joe’s real name, but I do remember my brother’s “obituary” and I won’t forget Mariah’s story
IV.           References
1.             D.A.R.E. [Internet]. The Official D.A.R.E. Web Site: Drug Abuse Resistance Education. Available from: http://www.dare.com/home/default.asp
2.             Ennett, Susan T., Rosenbaum, Dennis P., Flewelling, Robert L., Bieler, Gayle S., Ringwalt, Christopher L., Bailey, Susan L. Long-Term Evaluation of Drug Abuse Resistance Education. Addictive Behaviors. 1994;19(2):113–25.
3.             Objectives for D.A.R.E. School Curriculum [Internet]. 2012. Available from: http://www.dare.org/officers/Curriculum/Storyf98c.asp?N=Curriculum&M=10&S=12
4.             Rosenbaum, Dennis. Program Profile: Drug Abuse Resistance Education (DARE) [Internet]. University of Illinois at Chicago; Available from: http://crimesolutions.gov/ProgramDetails.aspx?ID=99
5.             Drug Abuse Resistance Education: The Effectiveness of DARE [Internet]. Alcohol Abuse Prevention: Some Serious Problems. Available from: http://www.alcoholfacts.org/DARE.html
6.             Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings [Internet]. U.S. Department of Health and Human Services Substance. Available from: http://www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm#3.2
7.             Ringwalt, Christopher, Greene, Jody M., Ennett, Susan T., Iachan, Ronaldo, Clayton, Richard R., Leukefeld, Carl G. Past and Future Directions of the D.A.R.E. Program: An Evaluation Review [Internet]. Research Triangle Institute; 1994 Sep. Available from: https://www.ncjrs.gov/txtfiles/darerev.txt
8.             Shephard III, Edward M. The Economic Costs of D.A.R.E. Institute of Industrial Relations; 2001 Nov.
9.             Ethnic Distribution of Pupils by District, Los Angeles County [Internet]. Los Angeles, CA; 1997 2011. Available from: http://www.laalmanac.com/education/ed05_97.htm
10.             Prevention & Education [Internet]. U.S. Department of Transportation; National Highway Traffic Safety Administration; 2001 Mar. Report No.: 4. Available from: http://www.nhtsa.gov/people/injury/alcohol/Community%20Guides%20HTML/Book4_Prevention.html#Current theories
11.             Thaler, Richard H., Sunstein, Cass R. Chapter 3: Following the Herd. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Press; 2008. page 53–71.
12.             DeFleur, Melvin L., Ball-Rokeach, Sandra J. Chapter 8: Socialization and Theories of Indirect Influence. Theories of Mass Communication (5th edition). White Plains, NY: Longman, Inc.; 1989. page 202–27.
13.             Marcoux, B.C., Shope, J.T. Application of the Theory of Planned Behavior to adolescent use and misuse of alcohol. Health Education Research: Theory and Practice. 1997;12(3):323–31.
14.             Edberg, Mark. Chapter 4: Individual Health Behavior Theories. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Washington, D.C.: Jones and Bartlett Publishers; 2007. page 191–205.
15.             CDC Vital Signs - Teen Drinking and Driving [Internet]. [cited 2012 Dec 13]. Available from: http://www.cdc.gov/vitalsigns/TeenDrinkingAndDriving/index.html
16.             Every 15 Minutes - Someone dies from an Alcohol Related Collision [Internet]. [cited 2012 Dec 14]. Available from: http://www.every15minutes.com/aboutus/
17.             Komro, Kelli A., Toomey, Traci L. Strategies to Prevent Underage Drinking. NIAAA Spectrum [Internet]. Available from: http://pubs.niaaa.nih.gov/publications/arh26-1/5-14.htm
18.             Grieving father offers teens money not to drink [Internet]. CNN. [cited 2012 Dec 14]. Available from: http://www.cnn.com/2012/06/14/us/cnnheroes-mccarthy-alcohol-challenge/index.html
19.             Holder, Harold D. Community Prevention of Young Adult Drinking and Associated Problems. NIAAA Spectrum.
20.             General S. Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking [Internet]. [cited 2012 Dec 14]. Available from: http://www.surgeongeneral.gov/library/calls/underagedrinking/programs.html
21.             What sways teens not to drink, drive? Stories, not stats [Internet]. CNN. [cited 2012 Dec 13]. Available from: http://www.cnn.com/2012/10/10/us/cnnheroes-underage-drunken-driving/index.html

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