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PREVENTIVE STRATEGIES IN EDUCATION: HISTORY, CURRENT PRACTICES, AND FUTURE TRENDS REGARDING SUBSTANCE ABUSE AND PREGNANCY PREVENTION* JACQUELYN G. SOWERS, ED.M. Sowers Associates Hampton, New Hampshire I F THE CURRICULUM is now too crowded to permit of the introduction of this [health] teaching, then we should cut out enough of the less useful subjects to make ample room for it... I We need only to remove the blinders from our eyes or to pick up any daily metropolitan newspaper and scan its headlines to realize that sex education is sadly lacking and that tomorrow's citizens are not being prepared for all phases of life.2 How fares alcohol education in this period? The drinks are placed before these boys and girls. They are invited, urged, ridiculed to try drinking. The teachings of home and school and church are remembered-but they often seem abstract, far-away, and visionary as compared to the present issue of "Will I be asked again, can I get in on other good times if I say "no?"3 ... For many years there has been an awareness of the need for this kind of [sex] education in our schools.... Still the schools are lagging. School administrators seem to have three fears: public response, how to get it into the curriculum, and finding qualified teachers.4
A review of the history of substance abuse and pregnancy prevention education in America over the past 90 years brought a wistful smile to my lips. Yes, the truism holds: the more things change (and they have) the more things remain the same. Since the turn of the century, caring adults have articulated the need for comprehensive health education with an eye toward prevention of harmful outcomes. There was understanding then, as now, of the need for the integration of the physical, mental, social, emotional, environmental, and spiritual dimensions of health. Thousands of programs have been proffered *Presented in a panel, State-of-the-Art in Prevention and Treatment Strategies, as part of a Symposium on Pregnancy and Substance Abuse: Perspectives and Directions held by the Committee on Public Health of the New York Academy of Medicine, the Medical and Health Research Association of New York City,
Columbia University School of Public Health, the Maternal and Child Health Program of the New York County Medical Society, the Greater New York March of Dimes, and Agenda for Children Tomorrow March 22, 1990 at the New York Academy of Medicine.
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and implemented; and thousands have been pushed aside in the quest for academic excellence at the expense of the development of personal health knowledge, skills, and attitudes that can help individuals make healthy behavioral choices. The practical and philosophical barriers to excellence in school health education that we face today, particularly in the fields of sexuality, contraception, and substance abuse, reiterate concerns of our forbears. Who shall teach? At what age should we broach sexuality or substance use? Where will these health lessons/courses be placed in our already overcrowded curriculum? Which disciplines are best for placement of health content? How can we assure age-appropriate education K-12? Doesn't primary responsibility for teaching about sexuality and substance use belong in the home? Shall we espouse a responsible use or an abstinence philosophy? What shall we do if parents object? What is the role of health professionals in the development and delivery of health education curricula? Since these issues are fraught with moral and ethical considerations, whose values shall we teach? What about the multicultural aspects of education about alcohol, other drugs, and sexuality? How will we know if our prevention efforts have had a positive influence on young people? Can education counter media messages and social realities that seem to push our children into substance use and sexual activity at earlier and earlier ages? Perennial questions. Evolving answers. The rest of this paper will briefly catalogue the most widespread educational strategies used over the past 25 years or so in substance abuse prevention and pregnancy prevention/sexuality education, and conclude with observations on emerging trends. EVOLUTION OF EDUCATIONAL APPROACHES TO SUBSTANCE ABUSE PREVENTION
Scare tactics. In the early 1960s marijuana began to spread from college campuses into high schools and other places where young people congregated. Parents and educators were duly alarmed. Drawing upon memories of earlier "reefer madness" education in the military, the first prevention efforts with school age youth were decidedly scary. The philosophy was "if we scare them with the horror of the consequences, they'll never start." Educational films then carried strong images of physical and mental illness, violence, blood, and gore resulting from drug use. Alcohol education also became more prevalent, often utilizing frightening scenes of the aftermath of drunk driving accidents or images of drunken men in the gutter. For a variety of reasons -the natural sense of invulnerability of adolescents ("It can't happen Vol. 67, No. 3, May-June 1991
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to me."), the natural reaction to hyperbole ("That's a little much."), the visual media sophistication of the television generation ("That's like John Wayne/Dean Martin/Clint Eastwood/Cheech and Chong/Rambo/etc. ") these and other reactions made scare tactics ineffective as substance use prevention motivators for most students. Moreover, for a few, the scare heightened the thrill of danger and served as a perverse motivator. Recovering addicts. Another common technique has used recovering alcoholics or drug abusers as classroom guest speakers or in film, tape, or print. The philosophy was to capture student attention and empathy for these people, followed by a personal message that said "Don't do what I did; stay away from alcohol and drugs." These classroom activities or assembly programs characteristically received positive reviews from students. They served as positive reinforcement for recovering addicts as well. However, the underlying message may have been stronger than the overt one. Many recovering addicts appear to have their lives together and may really be sending the message "You can drink or use, hit bottom, and bounce back when you really want to be a responsible adult, just like I did." Most educators no longer use the recovering addict strategy in the classroom. Information. By the 1970s many schools were using alcohol and drug prevention programs that contained extensive information about the nature of various substances, chemical composition, effects of use, danger of mixing pills, smoked or injected substances with alcohol, the short and long-term health consequences of each, and laws governing possession and use. These lessons were often presented by a law enforcement officer from the narcotics unit, complete with the pharmacopeia of samples of every common and notso-common street drug. The philosophy was that if students really knew the facts and understood the risks, they would not use. Critics were quick to point out that we were making extremely knowledgeable consumers out of our high school students. Substance use continued to increase and educators decided that scientific information was probably necessary, but certainly not sufficient to keep kids off drugs. Most teachers have begun to de-emphasize pharmacological and chemical detail in their instruction. Analysis of media pressures. A popular educational strategy to help students avoid harmful substances had them analyze advertising messages and general media presentations that encouraged cigarette smoking, alcohol use, or use of other drugs. There was no shortage of print and television advertising, movies, television soaps or sitcoms, MTV clips, rock songs, concerts, or tales of the private lives of the stars and athletes that young people revered or Bull. N.Y. Acad. Med.
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with whom they identified. The philosophy was that if we could get students aware and perhaps even a little annoyed, if not angry, about how they were being manipulated and pandered to, they would reject harmful behaviors and substances. As a rule, students enjoy this analysis, still used extensively in drug and alcohol prevention education curricula. Still, media messages are powerful, and some question whether they determine or simply mirror society's values with regard to substances. Either way, media analysis is probably a useful exercise, but certainly not enough to prevent substance use. Positive self-esteem. In a kind of reaction to the questionable impact of the preceding approaches to substance abuse prevention, many parents and educators turned to ways to promote self-esteem and positive feelings about oneself and one's value and worth as a person. It was believed the time had come for a more oblique approach to drug prevention, not a frontal one. Directing our energies to the enhancement of student self-esteem felt good. It was a positive, affirmative strategy and held promise of having salubrious effects on each student's life, making the use of drugs or alcohol unnecessary. Many schools still have programs designed to maintain and to enhance selfesteem, but few educators believe this is all there is to effective substance abuse prevention. It is another example of a necessary, desirable, but insufficient instructional approach. It is still given great attention by parent groups seeking strategies to enhance their children's chances of avoiding substance abuse. Decision-making skill development. Enter the believers in critical thinking skill development. They aver that students need to be taught how to make sound decisions in social contexts. Understanding how good decisions are made, practicing the process of problem statement, option identification, cost-benefit analysis, and risk reduction based upon analysis of all knowable factors; empowering students by helping them to recognize that they can think their way out of unhealthy situations and make good life decisions -this approach can really help. But knowing how to make a sound decision and actually doing it in the heat of a social situation are quite different things. Intellect does not always rise above passion. Again, decision-making is an important skill to be developed, but there is more to substance abuse prevention than this alone. Cognitive skills are simply not enough. Resistance to peer pressure. By the 1980s most substance abuse prevention education programs utilized some form of "social inoculation" approach. The philosophy was to make students able to resist the negative influences of their friends who were trying to get them to drink or to use other drugs or to Vol. 67, No. 3, May-June 1991
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behave in any health-destructive way. In its most elementary form, "Just Say No" was the catchword and rallying cry. It didn't take educators long to realize that this might be helpful for young children, but for junior high and high school age youth it was far too puerile in intent and practical effectiveness to do much good. More sophisticated elaborations in the form of "assertiveness skills" and "refusal skills" training proliferated at the secondary level. These protocols are useful life skills, helping people to find ways to say no when they want to without severing social relationships or being rejected for holier-than-thou posturing. Nevertheless, some educators believe that casting peers in a negative light is not a very productive strategy for educating adolescents. Adolescents need friends. They recoil when parents or other adults criticize their friends and jump to their defense. They do not naturally take to "resisting" their friends when the developmental requisite for belonging and friendship is so very acute. Besides, teens point out, overt "do it, do it, do it" pressures do not often exist in their lives. Peer pressure is really more of an internal expectation of ostracism. Refusal skills and resistance training may come in handier in dealing with adults than with their friends. Interdependence and connectedness. Recent educational strategies for substance abuse prevention take a more positive view of child and adolescent peer relationships and capitalize on young peoples' intense needs for social bonding. This approach is grounded in the philosophy that human beings need to look out for one another, care for and about one another's safety and well-being, build networks of support at home, at school, and in the neighborhood. Together we can create safer environments. We can see to it that no one goes too far. This approach is represented in such slogans as "Friends don't let friends drive drunk," or "He ain't heavy, he's my brother." This approach reinforces students' roles as big brothers and sisters, and as children and grandchildren of elders who may need their care, concern, and perhaps protection. Curricular materials with the theme of protecting-oneself-andothers-from-harm-because-we-care have met with positive responses from teenagers. Enabling students to know important facts, to recognize danger signals, and to develop practical strategies for intervention can empower them with skills and insights useful beyond substance abuse prevention. Instilling and reinforcing caring attitudes and behaviors avoids a negative edge and capitalizes on the natural idealism and commitment to friends that young people passionately espouse. Homelschool/community collaboration. Another approach extends the preceding one of interdependence and connectedness. It is rooted in recogniBull. N.Y. Acad. Med.
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tion that substance abuse prevention is more than the school's responsibility-it is the business of the home, business community, church, youth and family-serving agencies, law enforcement, civic groups, health clinics and medical centers where students are treated, and local foundations. Collaborative prevention efforts are well underway in a growing number of communities. The best programs have young people themselves in leadership and implementation roles. These programs go beyond the earlier community awareness programs that often alarmed parents and others but did not always result in positive, youth-supporting and health-promoting actions. Several communities instituted very tough school rules such as expulsion on first offense or other draconian steps, after a local call to arms about the "Drug Problem." Kicking kids out of school is an effective way to drive them into substance use and other troubling risk behaviors, a lesson learned the hard way by some very well-meaning individuals and communities. Newer community collaboration approaches have a shared philosophy that "This is a caring community and we don't let our kids fall through the cracks; we work together here on every front to stop substance availability, distribution, use, abuse, and addiction." Communitywide efforts with broad-based involvement of caring adults and young people can affirm normative values, offer proactive chemical-free activities, and create safety nets to catch youngsters early, before addictions or accidents occur. EVOLUTION OF EDUCATIONAL APPROACHES TO SEXUALITY AND PREGNANCY PREVENTION EDUCATION
There are certain historical parallels between pregnancy prevention and substance abuse prevention education over the years, although more schools have had units on drugs and alcohol than have had units on sex education. The extent and depth of sexuality education are more uneven and more subject to local parent and community pressures than are substance abuse prevention efforts. It is interesting to note that the national parent teachers' association has advocated sex education since its earliest founding in 1896. Gallup polls for 25 years indicate increasing support for sex education. Most parents are glad that schools do something to educate their children about pregnancy and disease prevention. Still, vocal individuals and groups locally can and do oppose sex education and diminish the effectiveness of program development and implementation in many communities. Administrators and teachers move cautiously and require strong parental and community support to institute an effective and comprehensive sexuality education program, K-12. Vol. 67, No. 3, May-June 1991
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As we have learned with substance abuse prevention efforts, information about the biological changes of puberty, conception, and pregnancy is necessary, but not sufficient, to prevent premature sexual activity and resulting health impacts. Most middle schools have lessons on growth and development and the bodily changes of puberty. Most high schools have courses that address the basics of reproductive biology, with lessons that explain how sperm and egg meet and ultimately became a baby. Some programs explain childbirth in complete detail, often using film or video. We have learned that a "just the facts" approach does not have as much impact on sexual behavior as we would wish. Even today, in many schools students can learn the facts of human reproduction, even make an A on the test, yet never make the personalized link to their behavior with a boyfriend or girlfriend. In the zeal to keep young people from having sex too soon and suffering untoward consequences, some programs have utilized thinly veiled scare tactics, often in the form of "don't ruin your life" messages. Others have managed to serve up a view of human sexuality as negative, nasty, hurtful, evil. Still others have taken sexist approaches like "if a pregnancy happens it's the girl's fault," "she asked for it," or "males are only out for one thing." A few have even resorted to condescending attempts at humor, such as "pet your dog, not your date." We have learned that, in addition to not being very effective with adolescents, these negative messages may contribute to the very lack of serious reflection, partner communication, and personal responsibility that we want to encourage among maturing young adults. Other educational programs have invited "recovering" teen-age parents to talk about how hard it is to have a baby, to be a good parent, to do what has to be done to grow up, to get an education, to make a living, and to become a fully functioning adult all at the same time. Educators have mixed feeling about the efficacy of these approaches in and of themselves. Young teen-age parents are often truly heroic. Most love their babies dearly. Being a parent is important! Many find new seriousness and purpose in their lives. Many are the objects of genuine compassion and care. Could there be some of the same double message that we found with the invitation of recovering addicts into the classroom? In the 1970s the issue of birth control became a major topic of conversation in the larger society and a major bone of contention in pregnancy prevention programming for youth. There were those who argued that education about birth control is an inalienable right of any person of childbearing age. Many schools invited agency nurses and educators to provide birth control information to high school and, in some places, junior high school students. Bull. N.Y. Acad. Med.
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During the late 1970s and early 1980s several communities piloted school based health clinics that, along with a variety of other important health services, dispensed information about birth control. A few even prescribed birth control pills or other devices, or gave out condoms along with counseling and referral. In spite of the successes in reducing the teen pregnancy rate in several studies, many parents and communities just could not condone dispensing birth control information or devices in the schools. There was a strong backlash from some parents and religious leaders who believed that providing birth control information, let alone prescribing pills or devices, was tantamount to giving teenagers license to have intercourse. In many communities, although probably not a majority, groups such as Planned Parenthood offered their services to instruct young people (young women primarily) in basic birth control information. In a parallel to the drug pharmacopoeia displays in substance abuse prevention education, family planning educators came into classrooms with displays illustrating various birth control devices, their reliability, and tips for effective use. At first, fundamentalist or conservative parents strenuously objected. Some parents also feared that clinics or classes that discussed abortion in this context were sending the message to teenagers that it was an alternative birth control method. Even among parents who supported a woman's right to abortion, most would prefer that their own daughters not have to make that choice, at least not as teenagers. Then, gradually, even more liberal, pro-sex education parents began to feel uneasy about the "we-know-you-are-determined-to-besexually-active-so-if-you're-going-to-do-it-be-responsible" approach. Abstinence as an educational message gained widespread favor during the 1980s. With the "just say no" campaign in full swing in drug prevention, many adults advocated adding sexual activity to the list of harmful behaviors. Some even went so far as to say, "let's don't talk about it; if we don't talk about it in school so much, maybe the kids won't think about doing it so much. " Some schools called a moratorium on all sex education. "Leave it to the home and the church." But the home and the church were apparently rather silent on sex and pregnancy prevention topics according to teenagers who reported in study after study that they continued to get their sex education information primarily from their peers and the media. One fallacy in the abstinence or "just say no" approach to sexuality is that although most parents would be perfectly happy if their children said no to cigarettes, alcohol, and other drugs forever, they are less comfortable with that message as applied to sexuality. Most parents want their children to be happy, fulfilled, and loving sexual adults. The most effective strategies utiVol. 67, No. 3, May-June 1991
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lize a "waiting is worth it" approach to discourage adolescent intercourse. Adults must have enough dialogue with young people about the meaning of sexuality, intimacy, love, and parenthood in people's lives that the youth will understand why a person could truly believe that waiting is worth it. By 1983-84 the abstinence and waiting-is-worth-it approaches got a powerful boost: AIDS loomed on the horizon. Other sexually transmitted disease rates were climbing, too, but it was the AIDS virus that got our attention. By the mid 1980s many schools began to reexamine health education programs and sexuality education offerings. Most districts found these lacking and far from comprehensive in their approach. Far too many schools conducted oneshot auditorium assembly programs on AIDS in the absence of any meaningful discussion or placing AIDS in a larger framework. Recognizing the shortcomings of such stop-gap education, community after community began to develop sounder comprehensive school health education guidelines and began to search for curriculum materials and instructional strategies that did more than just present the facts about sex, birth control, pregnancy, and sexually transmitted diseases, including AIDS. In sum, during the last half of the decade of the 1980s more and more parents of every political and religious persuasion expressed concerns about teenage sexual activity as too much, too soon, too mindless, too cavalier, too risky, whether birth control or disease prevention precautions were used or not. As we begin the 1990s there is a perceptible change in public attitude and school policies. Uneasiness about and outright opposition to sex education has slacked off. Even the most conservative critics -those who had been opposed to any form of sex education in the schools -are coming to the table to discuss how we can address these issues. It is now common for school systems nationwide to have parent-community advisory groups who are struggling with appropriate sexuality education, pregnancy prevention, and HIV prevention programming. There is currently greater parent-school communication and collaboration over this aspect of the school curriculum than any other. WHITHER SUBSTANCE ABUSE PREVENTION AND SEXUALITY EDUCATION IN THE 1990S?
As we move into the final decade of the 20th century, positive prevention in the form of comprehensive health education programming is on the rise. We are presently building upon the insights and the lessons from approaches we have used in the past. There is more involvement by parents, health Bull. N.Y. Acad. Med.
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professionals, clergy, and educators coming together to design locally appropriate prevention and education. New initiatives take into account failed approaches, inadvertent messages, and those that may be effective with a new twist here or another dimension added there. In addition, three new trends seem to be coming on strong. TREND I: RECOGNITION OF THE INTERRELATIONSHIPS AMONG ADOLESCENT RISK BEHAVIORS
Increasingly, educators, health professionals, social workers, public health policy analysts, parents, and other caring adults who work with youth are recognizing the dynamic interactions among and between various adolescent behaviors. Many young people drink to lose their inhibitions so that the sexual desires and/or expectations won't overwhelm them. One has sex with a not-so-special boyfriend simply to escape the deep depression that comes from the exit of her father from her life. Another does dope alone to tune out a world where everyone else is sharper, cooler, richer, tougher. One boy deals drugs to escape the ghetto's grasp, thinking he's smarter than the last one who got shot. Another engages in receptive prostitution in order to feed his coke habit, but he's not gay. Another figures that if she can just get pregnant, she'll get kicked out of her abusive, alcoholic home and get enough money to make it on her own. Another mixes pills and beer in order to keep a buzz on because it's the only way to deal with his sexual identity issues. For most kids, regardless of socioeconomic status or home/school locale, "partying" is defined as some admixture of substances, music, and sex, and adults are clearly not invited in body, spirit, or admonition. As we become more sophisticated in our recognition of these multiple interrelationships, especially those that exist between sexual behaviors and substance abuse, we are forced to become more sophisticated in our prevention strategies. Categorical approaches are on the wane, in spite of federal funding that still earmarks dollars. Creative state and local leaders are pooling monies and curricular approaches to move toward comprehensive school health education and interdisciplinary approaches. There has been evidence of an awakening of many school administrators and teachers who are not health education oriented. School boards are looking at their school offerings to determine where the many comprehensive health education knowledges, skills, and attitudes can be infused, integrated, and highlighted. Health, broadly defined, is the hidden basic. Most adults have now understood that double 800s on the SAT or straight As in English don't matter very much if Vol. 67, No. 3, May-June 1991
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he's an alcoholic at 14, she's a mom at 16, he's altered more than his muscles with steroids, or she's HIV positive at graduation. We are seeing a movement toward integrated programming that brings substance use prevention and pregnancy prevention into a unified, educational overture that is part of the comprehensive health education symphony. TREND II: ACKNOWLEDGEMENT OF POVERTY, RACISM, AND SEXISM AS MAJOR UNDERLYING FORCES IN YOUTH RISK BEHAVIORS REGARDING SUBSTANCES AND SEXUALITY
Slowly but surely, and never comfortably, political, public health, and educational leaders are being forced to acknowledge that youthful sexual and substance abusing behaviors are impacted to a large degree, if not caused, by the major socioeconomic forces of poverty, racism, and sexism. These forces impact men and women, boys and girls, sapping an individual's self-esteem, dreams for the future, and will to make good things happen for himself or herself. If poverty seems inevitable, if one is excluded or ridiculed or prejudged because of race, gender, religion, or ethnicity, if one is expected to behave in narrowly defined roles, if one sees his or her future muddied or clouded or filled with obstacles, why not just drink, drug, and get all you can at anyone's expense? If your life is not worth much to yourself or anyone else, who cares about health? "Live fast, die young, and have a good lookin' corpse." There are a few faint shapes on the horizon, a few voices arising from the chaos to direct our prevention efforts in broader directions. Some dare to question the "War on Drugs," asking if we perhaps might not be ready for another, more enlightened War on Poverty. Some dare to challenge programs for "At-Risk Youth," wondering if we might not be again assuring selffulfilling prophecies by labeling youngsters and their families. Some dare to suggest legalization of substances as a more effective way to control their use and distribution. Some dare to model male-female equality and responsibility in families. Some dare to call for welfare reform with incentives toward individual and family enhancement, not dependence. Some dare to sponsor parent and family leave bills in Congress to support the family as the cornerstone of care. Some dare to recommend that comprehensive school health education include attention to these issues of social health, broadly conceived. Could altering the negative power of any of these major societal forces make a difference in the teenage pregnancy rate? the alcohol addiction rate? the sexually transmitted disease rate? the overdose rate? the suicide rate? the HIV infection rate? There are advocates who believe the answer in every case Bull. N.Y. Acad. Med.
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is yes and are ready to support prevention strategies that sensitively address these forces without the stridency or polarization that has characterized some previous efforts. TREND III: RENEWED ATTENTION TO THE DEVELOPMENT OF MORAL/ETHICAL REASONING
As the 1990s began, there was a reawakening of concern with moral and ethical dimensions of health choices and behaviors across the board. What is right when it comes to issues of abortion, clean needle distribution programs, decriminalization of drug possession, condom dispensers in public restrooms, access to birth control for teenagers, to name a few hotly debated topics? What is right? What is just? What is best? What is healthiest? What is good for me? What is good for others? These are the kinds of moral and ethical questions people ask themselves every day. When these questions are about health issues in our lives, how we answer and act upon our judgments can have life and death consequences. We do have some recent history with regard to education about values and health. As American culture became increasingly diverse and heterogeneous over the past 30 years, and with the recognition of a "tossed salad" rather than a "melting pot" image of our societal milieu, educators moved further and further in the direction of so-called "value-free" instruction. Of course, everyone recognizes that no curriculum or instruction is value-free, but educators did attempt to legitimize the themes of equality and equity, with an affirmation of each and every child and family and their values. Under the name of respect for differences, teachers might say, "Whatever you believe about x is all right, just justify your point of view." Enormous effort went into creating curricula that respected the rights and differences among ethnic, religious, racial, regional, and socioeconomic groups, while affirming the core values of the United States Constitution. The Constitution, of course, has nothing to say about such topics as substance abuse or sexuality per se, and there certainly are value differences regarding these and other health issues. ("Doesn't teenage sexual activity and substance use fall under the constitutionally guaranteed right of "pursuit of happiness," one teenager asked seriously.) Teachers describe conflicts with parents where one family believes in teaching responsible use and another believes in total abstinence. Both want the school to reinforce deeply held convictions about what they believe is right for them and their children. It is difficult to teach such health topics as substance use/abuse in a valuefree manner, but some teachers did try. Most ultimately found this approach lacking, because when it comes to many health matters, some behaviors are Vol. 67, No. 3, May-June 1991
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better, healthier, "righter" than others. The general consensus among educators and parents now seems to be that we had better take a closer look at how we teach this matter of moral and ethical reasoning. Nearly everyone agrees that schools should teach thinking. Moral and ethical reasoning is the highest form of that skill. It can now be argued convincingly that there is no stronger content vehicle in the school curriculum for teaching moral and ethical reasoning than health. Have we really done an effective job of asking students to think about their sexual feelings and behaviors in moral/ethical terms? Have we asked them to analyze the moral/ethical dimensions of alcohol, street drug, steroid, or other drug use? Have we set up learning activities that cause them to think in terms of both short-term and long-term impacts, intended and unintended consequences of various behaviors? Can't we teach kids to think in moral ways without being bigoted, narrow, pedantic, or moralistic? Good teachers and wise parents know that it can be done. This is another frontier of teaching and learning toward prevention of harmful or life-limiting outcomes.
CONCLUSION
Substance abuse prevention and pregnancy prevention are two of the most important aspects of comprehensive school health education, pre-K-12. We have learned a great deal from our earnest efforts over many years, and are improving our professional awarenesses and implementation skills. We are talking across disciplines and professional demarcations -educators, physicians, nurses, social workers, psychologists, epidemiologists, clergy, family service professionals, law enforcement officials, and politicians-to reach broader understandings of the issues that face our children and adolescents. We are reaching out to involve parents in substantive ways. We are looking at the health of the environments in which our children learn and grow, including the family, neighborhood, and larger society, as well as the school. We are building the health service infrastructures that allow early identification and screening, prevention services, crisis intervention, and treatment referrals to happen more efficiently and effectively in schools. We are learning together that the most effective prevention approaches are positive life and health promotion strategies -strategies that not only teach youth knowledges and skills that enable them to avoid harm, but those which enable them to live life fully and envision a positive future for themselves, no matter their circumstances or origins. As we start the final decade of the 20th century, still concerned about adolescent sexuality and substance abuse statistics, we are poised for collaborative prevention action that is less negative, Bull. N.Y. Acad. Med.
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punitive, and nay-saying, instead focusing on health education that informs, invites, and inspires young people to care about their healthy futures and act affirmatively, rather than destructively, to make their dreams come true. REFERENCES 1. Egbert, S.: School hygiene and the teaching of hygiene in the public schools. Am. Phys. Educ. Rev. 9:1904. 2. Leibee, H.C.: A sex education program. J. Health Phys. Educ.: November 1937. 3. Breg, W.R.: An activity program in alco-
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hol education. J. Health Phys. Educ. 12 (10): 1941. 4. Manley, H.: Sex education: where, when, and how should it be taught? J. Health Phys. Educ. Rec.: March 1941.
PREVENTIVE STRATEGIES IN EDUCATION: HISTORY, CURRENT PRACTICES, AND FUTURE TRENDS REGARDING SUBSTANCE ABUSE AND PREGNANCY PREVENTION* JACQUELYN G. SOWERS, ED.M. Sowers Associates Hampton, New Hampshire I F THE CURRICULUM is now too crowded to permit of the introduction of this [health] teaching, then we should cut out enough of the less useful subjects to make ample room for it... I We need only to remove the blinders from our eyes or to pick up any daily metropolitan newspaper and scan its headlines to realize that sex education is sadly lacking and that tomorrow's citizens are not being prepared for all phases of life.2 How fares alcohol education in this period? The drinks are placed before these boys and girls. They are invited, urged, ridiculed to try drinking. The teachings of home and school and church are remembered-but they often seem abstract, far-away, and visionary as compared to the present issue of "Will I be asked again, can I get in on other good times if I say "no?"3 ... For many years there has been an awareness of the need for this kind of [sex] education in our schools.... Still the schools are lagging. School administrators seem to have three fears: public response, how to get it into the curriculum, and finding qualified teachers.4
A review of the history of substance abuse and pregnancy prevention education in America over the past 90 years brought a wistful smile to my lips. Yes, the truism holds: the more things change (and they have) the more things remain the same. Since the turn of the century, caring adults have articulated the need for comprehensive health education with an eye toward prevention of harmful outcomes. There was understanding then, as now, of the need for the integration of the physical, mental, social, emotional, environmental, and spiritual dimensions of health. Thousands of programs have been proffered *Presented in a panel, State-of-the-Art in Prevention and Treatment Strategies, as part of a Symposium on Pregnancy and Substance Abuse: Perspectives and Directions held by the Committee on Public Health of the New York Academy of Medicine, the Medical and Health Research Association of New York City,
Columbia University School of Public Health, the Maternal and Child Health Program of the New York County Medical Society, the Greater New York March of Dimes, and Agenda for Children Tomorrow March 22, 1990 at the New York Academy of Medicine.
Bull. N.Y. Acad. Med.
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and implemented; and thousands have been pushed aside in the quest for academic excellence at the expense of the development of personal health knowledge, skills, and attitudes that can help individuals make healthy behavioral choices. The practical and philosophical barriers to excellence in school health education that we face today, particularly in the fields of sexuality, contraception, and substance abuse, reiterate concerns of our forbears. Who shall teach? At what age should we broach sexuality or substance use? Where will these health lessons/courses be placed in our already overcrowded curriculum? Which disciplines are best for placement of health content? How can we assure age-appropriate education K-12? Doesn't primary responsibility for teaching about sexuality and substance use belong in the home? Shall we espouse a responsible use or an abstinence philosophy? What shall we do if parents object? What is the role of health professionals in the development and delivery of health education curricula? Since these issues are fraught with moral and ethical considerations, whose values shall we teach? What about the multicultural aspects of education about alcohol, other drugs, and sexuality? How will we know if our prevention efforts have had a positive influence on young people? Can education counter media messages and social realities that seem to push our children into substance use and sexual activity at earlier and earlier ages? Perennial questions. Evolving answers. The rest of this paper will briefly catalogue the most widespread educational strategies used over the past 25 years or so in substance abuse prevention and pregnancy prevention/sexuality education, and conclude with observations on emerging trends. EVOLUTION OF EDUCATIONAL APPROACHES TO SUBSTANCE ABUSE PREVENTION
Scare tactics. In the early 1960s marijuana began to spread from college campuses into high schools and other places where young people congregated. Parents and educators were duly alarmed. Drawing upon memories of earlier "reefer madness" education in the military, the first prevention efforts with school age youth were decidedly scary. The philosophy was "if we scare them with the horror of the consequences, they'll never start." Educational films then carried strong images of physical and mental illness, violence, blood, and gore resulting from drug use. Alcohol education also became more prevalent, often utilizing frightening scenes of the aftermath of drunk driving accidents or images of drunken men in the gutter. For a variety of reasons -the natural sense of invulnerability of adolescents ("It can't happen Vol. 67, No. 3, May-June 1991
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to me."), the natural reaction to hyperbole ("That's a little much."), the visual media sophistication of the television generation ("That's like John Wayne/Dean Martin/Clint Eastwood/Cheech and Chong/Rambo/etc. ") these and other reactions made scare tactics ineffective as substance use prevention motivators for most students. Moreover, for a few, the scare heightened the thrill of danger and served as a perverse motivator. Recovering addicts. Another common technique has used recovering alcoholics or drug abusers as classroom guest speakers or in film, tape, or print. The philosophy was to capture student attention and empathy for these people, followed by a personal message that said "Don't do what I did; stay away from alcohol and drugs." These classroom activities or assembly programs characteristically received positive reviews from students. They served as positive reinforcement for recovering addicts as well. However, the underlying message may have been stronger than the overt one. Many recovering addicts appear to have their lives together and may really be sending the message "You can drink or use, hit bottom, and bounce back when you really want to be a responsible adult, just like I did." Most educators no longer use the recovering addict strategy in the classroom. Information. By the 1970s many schools were using alcohol and drug prevention programs that contained extensive information about the nature of various substances, chemical composition, effects of use, danger of mixing pills, smoked or injected substances with alcohol, the short and long-term health consequences of each, and laws governing possession and use. These lessons were often presented by a law enforcement officer from the narcotics unit, complete with the pharmacopeia of samples of every common and notso-common street drug. The philosophy was that if students really knew the facts and understood the risks, they would not use. Critics were quick to point out that we were making extremely knowledgeable consumers out of our high school students. Substance use continued to increase and educators decided that scientific information was probably necessary, but certainly not sufficient to keep kids off drugs. Most teachers have begun to de-emphasize pharmacological and chemical detail in their instruction. Analysis of media pressures. A popular educational strategy to help students avoid harmful substances had them analyze advertising messages and general media presentations that encouraged cigarette smoking, alcohol use, or use of other drugs. There was no shortage of print and television advertising, movies, television soaps or sitcoms, MTV clips, rock songs, concerts, or tales of the private lives of the stars and athletes that young people revered or Bull. N.Y. Acad. Med.
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with whom they identified. The philosophy was that if we could get students aware and perhaps even a little annoyed, if not angry, about how they were being manipulated and pandered to, they would reject harmful behaviors and substances. As a rule, students enjoy this analysis, still used extensively in drug and alcohol prevention education curricula. Still, media messages are powerful, and some question whether they determine or simply mirror society's values with regard to substances. Either way, media analysis is probably a useful exercise, but certainly not enough to prevent substance use. Positive self-esteem. In a kind of reaction to the questionable impact of the preceding approaches to substance abuse prevention, many parents and educators turned to ways to promote self-esteem and positive feelings about oneself and one's value and worth as a person. It was believed the time had come for a more oblique approach to drug prevention, not a frontal one. Directing our energies to the enhancement of student self-esteem felt good. It was a positive, affirmative strategy and held promise of having salubrious effects on each student's life, making the use of drugs or alcohol unnecessary. Many schools still have programs designed to maintain and to enhance selfesteem, but few educators believe this is all there is to effective substance abuse prevention. It is another example of a necessary, desirable, but insufficient instructional approach. It is still given great attention by parent groups seeking strategies to enhance their children's chances of avoiding substance abuse. Decision-making skill development. Enter the believers in critical thinking skill development. They aver that students need to be taught how to make sound decisions in social contexts. Understanding how good decisions are made, practicing the process of problem statement, option identification, cost-benefit analysis, and risk reduction based upon analysis of all knowable factors; empowering students by helping them to recognize that they can think their way out of unhealthy situations and make good life decisions -this approach can really help. But knowing how to make a sound decision and actually doing it in the heat of a social situation are quite different things. Intellect does not always rise above passion. Again, decision-making is an important skill to be developed, but there is more to substance abuse prevention than this alone. Cognitive skills are simply not enough. Resistance to peer pressure. By the 1980s most substance abuse prevention education programs utilized some form of "social inoculation" approach. The philosophy was to make students able to resist the negative influences of their friends who were trying to get them to drink or to use other drugs or to Vol. 67, No. 3, May-June 1991
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behave in any health-destructive way. In its most elementary form, "Just Say No" was the catchword and rallying cry. It didn't take educators long to realize that this might be helpful for young children, but for junior high and high school age youth it was far too puerile in intent and practical effectiveness to do much good. More sophisticated elaborations in the form of "assertiveness skills" and "refusal skills" training proliferated at the secondary level. These protocols are useful life skills, helping people to find ways to say no when they want to without severing social relationships or being rejected for holier-than-thou posturing. Nevertheless, some educators believe that casting peers in a negative light is not a very productive strategy for educating adolescents. Adolescents need friends. They recoil when parents or other adults criticize their friends and jump to their defense. They do not naturally take to "resisting" their friends when the developmental requisite for belonging and friendship is so very acute. Besides, teens point out, overt "do it, do it, do it" pressures do not often exist in their lives. Peer pressure is really more of an internal expectation of ostracism. Refusal skills and resistance training may come in handier in dealing with adults than with their friends. Interdependence and connectedness. Recent educational strategies for substance abuse prevention take a more positive view of child and adolescent peer relationships and capitalize on young peoples' intense needs for social bonding. This approach is grounded in the philosophy that human beings need to look out for one another, care for and about one another's safety and well-being, build networks of support at home, at school, and in the neighborhood. Together we can create safer environments. We can see to it that no one goes too far. This approach is represented in such slogans as "Friends don't let friends drive drunk," or "He ain't heavy, he's my brother." This approach reinforces students' roles as big brothers and sisters, and as children and grandchildren of elders who may need their care, concern, and perhaps protection. Curricular materials with the theme of protecting-oneself-andothers-from-harm-because-we-care have met with positive responses from teenagers. Enabling students to know important facts, to recognize danger signals, and to develop practical strategies for intervention can empower them with skills and insights useful beyond substance abuse prevention. Instilling and reinforcing caring attitudes and behaviors avoids a negative edge and capitalizes on the natural idealism and commitment to friends that young people passionately espouse. Homelschool/community collaboration. Another approach extends the preceding one of interdependence and connectedness. It is rooted in recogniBull. N.Y. Acad. Med.
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tion that substance abuse prevention is more than the school's responsibility-it is the business of the home, business community, church, youth and family-serving agencies, law enforcement, civic groups, health clinics and medical centers where students are treated, and local foundations. Collaborative prevention efforts are well underway in a growing number of communities. The best programs have young people themselves in leadership and implementation roles. These programs go beyond the earlier community awareness programs that often alarmed parents and others but did not always result in positive, youth-supporting and health-promoting actions. Several communities instituted very tough school rules such as expulsion on first offense or other draconian steps, after a local call to arms about the "Drug Problem." Kicking kids out of school is an effective way to drive them into substance use and other troubling risk behaviors, a lesson learned the hard way by some very well-meaning individuals and communities. Newer community collaboration approaches have a shared philosophy that "This is a caring community and we don't let our kids fall through the cracks; we work together here on every front to stop substance availability, distribution, use, abuse, and addiction." Communitywide efforts with broad-based involvement of caring adults and young people can affirm normative values, offer proactive chemical-free activities, and create safety nets to catch youngsters early, before addictions or accidents occur. EVOLUTION OF EDUCATIONAL APPROACHES TO SEXUALITY AND PREGNANCY PREVENTION EDUCATION
There are certain historical parallels between pregnancy prevention and substance abuse prevention education over the years, although more schools have had units on drugs and alcohol than have had units on sex education. The extent and depth of sexuality education are more uneven and more subject to local parent and community pressures than are substance abuse prevention efforts. It is interesting to note that the national parent teachers' association has advocated sex education since its earliest founding in 1896. Gallup polls for 25 years indicate increasing support for sex education. Most parents are glad that schools do something to educate their children about pregnancy and disease prevention. Still, vocal individuals and groups locally can and do oppose sex education and diminish the effectiveness of program development and implementation in many communities. Administrators and teachers move cautiously and require strong parental and community support to institute an effective and comprehensive sexuality education program, K-12. Vol. 67, No. 3, May-June 1991
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As we have learned with substance abuse prevention efforts, information about the biological changes of puberty, conception, and pregnancy is necessary, but not sufficient, to prevent premature sexual activity and resulting health impacts. Most middle schools have lessons on growth and development and the bodily changes of puberty. Most high schools have courses that address the basics of reproductive biology, with lessons that explain how sperm and egg meet and ultimately became a baby. Some programs explain childbirth in complete detail, often using film or video. We have learned that a "just the facts" approach does not have as much impact on sexual behavior as we would wish. Even today, in many schools students can learn the facts of human reproduction, even make an A on the test, yet never make the personalized link to their behavior with a boyfriend or girlfriend. In the zeal to keep young people from having sex too soon and suffering untoward consequences, some programs have utilized thinly veiled scare tactics, often in the form of "don't ruin your life" messages. Others have managed to serve up a view of human sexuality as negative, nasty, hurtful, evil. Still others have taken sexist approaches like "if a pregnancy happens it's the girl's fault," "she asked for it," or "males are only out for one thing." A few have even resorted to condescending attempts at humor, such as "pet your dog, not your date." We have learned that, in addition to not being very effective with adolescents, these negative messages may contribute to the very lack of serious reflection, partner communication, and personal responsibility that we want to encourage among maturing young adults. Other educational programs have invited "recovering" teen-age parents to talk about how hard it is to have a baby, to be a good parent, to do what has to be done to grow up, to get an education, to make a living, and to become a fully functioning adult all at the same time. Educators have mixed feeling about the efficacy of these approaches in and of themselves. Young teen-age parents are often truly heroic. Most love their babies dearly. Being a parent is important! Many find new seriousness and purpose in their lives. Many are the objects of genuine compassion and care. Could there be some of the same double message that we found with the invitation of recovering addicts into the classroom? In the 1970s the issue of birth control became a major topic of conversation in the larger society and a major bone of contention in pregnancy prevention programming for youth. There were those who argued that education about birth control is an inalienable right of any person of childbearing age. Many schools invited agency nurses and educators to provide birth control information to high school and, in some places, junior high school students. Bull. N.Y. Acad. Med.
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During the late 1970s and early 1980s several communities piloted school based health clinics that, along with a variety of other important health services, dispensed information about birth control. A few even prescribed birth control pills or other devices, or gave out condoms along with counseling and referral. In spite of the successes in reducing the teen pregnancy rate in several studies, many parents and communities just could not condone dispensing birth control information or devices in the schools. There was a strong backlash from some parents and religious leaders who believed that providing birth control information, let alone prescribing pills or devices, was tantamount to giving teenagers license to have intercourse. In many communities, although probably not a majority, groups such as Planned Parenthood offered their services to instruct young people (young women primarily) in basic birth control information. In a parallel to the drug pharmacopoeia displays in substance abuse prevention education, family planning educators came into classrooms with displays illustrating various birth control devices, their reliability, and tips for effective use. At first, fundamentalist or conservative parents strenuously objected. Some parents also feared that clinics or classes that discussed abortion in this context were sending the message to teenagers that it was an alternative birth control method. Even among parents who supported a woman's right to abortion, most would prefer that their own daughters not have to make that choice, at least not as teenagers. Then, gradually, even more liberal, pro-sex education parents began to feel uneasy about the "we-know-you-are-determined-to-besexually-active-so-if-you're-going-to-do-it-be-responsible" approach. Abstinence as an educational message gained widespread favor during the 1980s. With the "just say no" campaign in full swing in drug prevention, many adults advocated adding sexual activity to the list of harmful behaviors. Some even went so far as to say, "let's don't talk about it; if we don't talk about it in school so much, maybe the kids won't think about doing it so much. " Some schools called a moratorium on all sex education. "Leave it to the home and the church." But the home and the church were apparently rather silent on sex and pregnancy prevention topics according to teenagers who reported in study after study that they continued to get their sex education information primarily from their peers and the media. One fallacy in the abstinence or "just say no" approach to sexuality is that although most parents would be perfectly happy if their children said no to cigarettes, alcohol, and other drugs forever, they are less comfortable with that message as applied to sexuality. Most parents want their children to be happy, fulfilled, and loving sexual adults. The most effective strategies utiVol. 67, No. 3, May-June 1991
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lize a "waiting is worth it" approach to discourage adolescent intercourse. Adults must have enough dialogue with young people about the meaning of sexuality, intimacy, love, and parenthood in people's lives that the youth will understand why a person could truly believe that waiting is worth it. By 1983-84 the abstinence and waiting-is-worth-it approaches got a powerful boost: AIDS loomed on the horizon. Other sexually transmitted disease rates were climbing, too, but it was the AIDS virus that got our attention. By the mid 1980s many schools began to reexamine health education programs and sexuality education offerings. Most districts found these lacking and far from comprehensive in their approach. Far too many schools conducted oneshot auditorium assembly programs on AIDS in the absence of any meaningful discussion or placing AIDS in a larger framework. Recognizing the shortcomings of such stop-gap education, community after community began to develop sounder comprehensive school health education guidelines and began to search for curriculum materials and instructional strategies that did more than just present the facts about sex, birth control, pregnancy, and sexually transmitted diseases, including AIDS. In sum, during the last half of the decade of the 1980s more and more parents of every political and religious persuasion expressed concerns about teenage sexual activity as too much, too soon, too mindless, too cavalier, too risky, whether birth control or disease prevention precautions were used or not. As we begin the 1990s there is a perceptible change in public attitude and school policies. Uneasiness about and outright opposition to sex education has slacked off. Even the most conservative critics -those who had been opposed to any form of sex education in the schools -are coming to the table to discuss how we can address these issues. It is now common for school systems nationwide to have parent-community advisory groups who are struggling with appropriate sexuality education, pregnancy prevention, and HIV prevention programming. There is currently greater parent-school communication and collaboration over this aspect of the school curriculum than any other. WHITHER SUBSTANCE ABUSE PREVENTION AND SEXUALITY EDUCATION IN THE 1990S?
As we move into the final decade of the 20th century, positive prevention in the form of comprehensive health education programming is on the rise. We are presently building upon the insights and the lessons from approaches we have used in the past. There is more involvement by parents, health Bull. N.Y. Acad. Med.
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professionals, clergy, and educators coming together to design locally appropriate prevention and education. New initiatives take into account failed approaches, inadvertent messages, and those that may be effective with a new twist here or another dimension added there. In addition, three new trends seem to be coming on strong. TREND I: RECOGNITION OF THE INTERRELATIONSHIPS AMONG ADOLESCENT RISK BEHAVIORS
Increasingly, educators, health professionals, social workers, public health policy analysts, parents, and other caring adults who work with youth are recognizing the dynamic interactions among and between various adolescent behaviors. Many young people drink to lose their inhibitions so that the sexual desires and/or expectations won't overwhelm them. One has sex with a not-so-special boyfriend simply to escape the deep depression that comes from the exit of her father from her life. Another does dope alone to tune out a world where everyone else is sharper, cooler, richer, tougher. One boy deals drugs to escape the ghetto's grasp, thinking he's smarter than the last one who got shot. Another engages in receptive prostitution in order to feed his coke habit, but he's not gay. Another figures that if she can just get pregnant, she'll get kicked out of her abusive, alcoholic home and get enough money to make it on her own. Another mixes pills and beer in order to keep a buzz on because it's the only way to deal with his sexual identity issues. For most kids, regardless of socioeconomic status or home/school locale, "partying" is defined as some admixture of substances, music, and sex, and adults are clearly not invited in body, spirit, or admonition. As we become more sophisticated in our recognition of these multiple interrelationships, especially those that exist between sexual behaviors and substance abuse, we are forced to become more sophisticated in our prevention strategies. Categorical approaches are on the wane, in spite of federal funding that still earmarks dollars. Creative state and local leaders are pooling monies and curricular approaches to move toward comprehensive school health education and interdisciplinary approaches. There has been evidence of an awakening of many school administrators and teachers who are not health education oriented. School boards are looking at their school offerings to determine where the many comprehensive health education knowledges, skills, and attitudes can be infused, integrated, and highlighted. Health, broadly defined, is the hidden basic. Most adults have now understood that double 800s on the SAT or straight As in English don't matter very much if Vol. 67, No. 3, May-June 1991
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he's an alcoholic at 14, she's a mom at 16, he's altered more than his muscles with steroids, or she's HIV positive at graduation. We are seeing a movement toward integrated programming that brings substance use prevention and pregnancy prevention into a unified, educational overture that is part of the comprehensive health education symphony. TREND II: ACKNOWLEDGEMENT OF POVERTY, RACISM, AND SEXISM AS MAJOR UNDERLYING FORCES IN YOUTH RISK BEHAVIORS REGARDING SUBSTANCES AND SEXUALITY
Slowly but surely, and never comfortably, political, public health, and educational leaders are being forced to acknowledge that youthful sexual and substance abusing behaviors are impacted to a large degree, if not caused, by the major socioeconomic forces of poverty, racism, and sexism. These forces impact men and women, boys and girls, sapping an individual's self-esteem, dreams for the future, and will to make good things happen for himself or herself. If poverty seems inevitable, if one is excluded or ridiculed or prejudged because of race, gender, religion, or ethnicity, if one is expected to behave in narrowly defined roles, if one sees his or her future muddied or clouded or filled with obstacles, why not just drink, drug, and get all you can at anyone's expense? If your life is not worth much to yourself or anyone else, who cares about health? "Live fast, die young, and have a good lookin' corpse." There are a few faint shapes on the horizon, a few voices arising from the chaos to direct our prevention efforts in broader directions. Some dare to question the "War on Drugs," asking if we perhaps might not be ready for another, more enlightened War on Poverty. Some dare to challenge programs for "At-Risk Youth," wondering if we might not be again assuring selffulfilling prophecies by labeling youngsters and their families. Some dare to suggest legalization of substances as a more effective way to control their use and distribution. Some dare to model male-female equality and responsibility in families. Some dare to call for welfare reform with incentives toward individual and family enhancement, not dependence. Some dare to sponsor parent and family leave bills in Congress to support the family as the cornerstone of care. Some dare to recommend that comprehensive school health education include attention to these issues of social health, broadly conceived. Could altering the negative power of any of these major societal forces make a difference in the teenage pregnancy rate? the alcohol addiction rate? the sexually transmitted disease rate? the overdose rate? the suicide rate? the HIV infection rate? There are advocates who believe the answer in every case Bull. N.Y. Acad. Med.
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is yes and are ready to support prevention strategies that sensitively address these forces without the stridency or polarization that has characterized some previous efforts. TREND III: RENEWED ATTENTION TO THE DEVELOPMENT OF MORAL/ETHICAL REASONING
As the 1990s began, there was a reawakening of concern with moral and ethical dimensions of health choices and behaviors across the board. What is right when it comes to issues of abortion, clean needle distribution programs, decriminalization of drug possession, condom dispensers in public restrooms, access to birth control for teenagers, to name a few hotly debated topics? What is right? What is just? What is best? What is healthiest? What is good for me? What is good for others? These are the kinds of moral and ethical questions people ask themselves every day. When these questions are about health issues in our lives, how we answer and act upon our judgments can have life and death consequences. We do have some recent history with regard to education about values and health. As American culture became increasingly diverse and heterogeneous over the past 30 years, and with the recognition of a "tossed salad" rather than a "melting pot" image of our societal milieu, educators moved further and further in the direction of so-called "value-free" instruction. Of course, everyone recognizes that no curriculum or instruction is value-free, but educators did attempt to legitimize the themes of equality and equity, with an affirmation of each and every child and family and their values. Under the name of respect for differences, teachers might say, "Whatever you believe about x is all right, just justify your point of view." Enormous effort went into creating curricula that respected the rights and differences among ethnic, religious, racial, regional, and socioeconomic groups, while affirming the core values of the United States Constitution. The Constitution, of course, has nothing to say about such topics as substance abuse or sexuality per se, and there certainly are value differences regarding these and other health issues. ("Doesn't teenage sexual activity and substance use fall under the constitutionally guaranteed right of "pursuit of happiness," one teenager asked seriously.) Teachers describe conflicts with parents where one family believes in teaching responsible use and another believes in total abstinence. Both want the school to reinforce deeply held convictions about what they believe is right for them and their children. It is difficult to teach such health topics as substance use/abuse in a valuefree manner, but some teachers did try. Most ultimately found this approach lacking, because when it comes to many health matters, some behaviors are Vol. 67, No. 3, May-June 1991
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better, healthier, "righter" than others. The general consensus among educators and parents now seems to be that we had better take a closer look at how we teach this matter of moral and ethical reasoning. Nearly everyone agrees that schools should teach thinking. Moral and ethical reasoning is the highest form of that skill. It can now be argued convincingly that there is no stronger content vehicle in the school curriculum for teaching moral and ethical reasoning than health. Have we really done an effective job of asking students to think about their sexual feelings and behaviors in moral/ethical terms? Have we asked them to analyze the moral/ethical dimensions of alcohol, street drug, steroid, or other drug use? Have we set up learning activities that cause them to think in terms of both short-term and long-term impacts, intended and unintended consequences of various behaviors? Can't we teach kids to think in moral ways without being bigoted, narrow, pedantic, or moralistic? Good teachers and wise parents know that it can be done. This is another frontier of teaching and learning toward prevention of harmful or life-limiting outcomes.
CONCLUSION
Substance abuse prevention and pregnancy prevention are two of the most important aspects of comprehensive school health education, pre-K-12. We have learned a great deal from our earnest efforts over many years, and are improving our professional awarenesses and implementation skills. We are talking across disciplines and professional demarcations -educators, physicians, nurses, social workers, psychologists, epidemiologists, clergy, family service professionals, law enforcement officials, and politicians-to reach broader understandings of the issues that face our children and adolescents. We are reaching out to involve parents in substantive ways. We are looking at the health of the environments in which our children learn and grow, including the family, neighborhood, and larger society, as well as the school. We are building the health service infrastructures that allow early identification and screening, prevention services, crisis intervention, and treatment referrals to happen more efficiently and effectively in schools. We are learning together that the most effective prevention approaches are positive life and health promotion strategies -strategies that not only teach youth knowledges and skills that enable them to avoid harm, but those which enable them to live life fully and envision a positive future for themselves, no matter their circumstances or origins. As we start the final decade of the 20th century, still concerned about adolescent sexuality and substance abuse statistics, we are poised for collaborative prevention action that is less negative, Bull. N.Y. Acad. Med.
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punitive, and nay-saying, instead focusing on health education that informs, invites, and inspires young people to care about their healthy futures and act affirmatively, rather than destructively, to make their dreams come true. REFERENCES 1. Egbert, S.: School hygiene and the teaching of hygiene in the public schools. Am. Phys. Educ. Rev. 9:1904. 2. Leibee, H.C.: A sex education program. J. Health Phys. Educ.: November 1937. 3. Breg, W.R.: An activity program in alco-
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hol education. J. Health Phys. Educ. 12 (10): 1941. 4. Manley, H.: Sex education: where, when, and how should it be taught? J. Health Phys. Educ. Rec.: March 1941.
