T h e R o l e o f Sc h o o l s in S u b s t a n c e U s e P re v e n t i o n and Intervention Margaret M. Benningfield, MD, MSCIa,*, Paula Riggs, Sharon Hoover Stephan, PhDc
MD
b
,
KEYWORDS Substance use disorder Adolescent School mental health KEY POINTS Schools provide an ideal setting for screening, brief interventions, and outpatient treatment of substance use disorders (SUD). Individual treatment for SUD is effective at decreasing substance use as well as substance-related harm. In some contexts, rather than being helpful, group interventions can result in harm to participants; therefore, individual treatment may be preferred. Early interventions for adolescents using alcohol and other drugs (AOD) are generally effective in decreasing frequency and quantity of AOD use and decreasing risky behaviors.
INTRODUCTION
Most youth who have mental health problems do not receive appropriate services. This treatment gap is especially pronounced for problems related to or co-occurring with substance use.1 In the United States, about 5% of youth aged 12 to 17 will develop a substance use disorder (SUD) each year, but fewer than 10% of the 1.3 million youth who meet diagnostic criteria for a SUD receive treatment.2 Many schools implement evidence-based drug/alcohol prevention programs; however, the vast majority of these programs target youth who have not yet initiated substance use. In the community, the vast majority of adolescents who receive treatment are mandated to receive care by juvenile justice. Treatment resources are extremely limited for the estimated 10% to 15% of high school students who regularly use or
a Division of Child and Adolescent Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA; b Division of Substance Dependence, School of Medicine, Mail Stop F478, 12469 East 17th Place, Building 400, Aurora, CO 80045, USA; c Center for School Mental Health, Division of Child and Adolescent Psychiatry, University of Maryland School of Medicine, 737 West Lombard Street, 426, Baltimore, MD 21201, USA * Corresponding author. E-mail address: [email protected]
Child Adolesc Psychiatric Clin N Am 24 (2015) 291–303 http://dx.doi.org/10.1016/j.chc.2014.12.004 childpsych.theclinics.com 1056-4993/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
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Abbreviations ACRA AOD CBT CM CYT MDFT MET SUD
Adolescent Community Reinforcement Approach Alcohol and other drugs Cognitive–behavioral therapy Contingency management Cannabis Youth Treatment Multidimensional family therapy Motivational enhancement therapy Substance use disorder
meet diagnostic criteria for a SUD, but who are not (yet) involved with the juvenile justice system. Co-locating high-quality substance/behavioral health treatment in schools, including in school-based health centers, has the potential to improve screening, treatment access and availability, continuing care, and coordination of medical/behavioral health care.3 Compared with community-based treatment settings, youth who have access to school-based health centers are 10 times more likely to make a mental health or substance use visit and participate in screening for other high-risk behaviors.4 Implementing evidenced-based substance treatment interventions in schools also has the potential to reach youth at earlier stages of substance severity and to reduce the risk of progression to more chronic addiction with considerable cost savings to society.5 PREVALENCE OF SUBSTANCE USE IN ADOLESCENTS
The National Survey on Drug Use and Health found that 2.2 million youth ages 12 to 17 years reported using illicit drugs in the past month and 1.6 million youth reported binge drinking (consuming 4 or more drinks in 1 sitting for females or 5 or more drinks in 1 sitting for males) in the past month.2 Most youth who engage in substance use do not meet diagnostic criteria for clinical disorders; however, any substance use during adolescence is concerning because the risk for developing a SUD increases significantly with earlier age of initiation of use.6 For each year beyond age 14 that first alcohol use is delayed, the odds of subsequent alcohol use disorder drop by 14%. Lifetime prevalence of alcohol dependence was nearly 40% in those who reported first drinking alcohol before age 14 compared with about 10% in those who started drinking at age 20 or older.6 Thus, efforts to delay the initiation of substance use may significantly impact public health and dramatically decrease the cost to society of SUD. SCHOOL BASED PREVENTION OF SUBSTANCE USE DISORDERS School Climate and Connectedness
Connection with school has a bidirectional relationship with adolescent substance use. Youth who drop out of school have a significantly increased risk for cigarette, marijuana, and alcohol use and those who use alcohol and other drugs (AOD) are more likely to leave school.7 School connectedness is characterized by students having positive relationships with teachers, administrators, and peers at school and expressing a sense of commitment to the school. Connectedness is facilitated by provision of a safe learning environment where students feel they are treated fairly. Even in ideal circumstances, school connectedness often declines as youth enter middle school8—a time when rates of AOD use are on the rise. In a study of more than 2000 students, low school connectedness was associated with a 2-fold increase in regular alcohol
Substance Use Prevention and Intervention
drinking, cigarette smoking, and marijuana use.9 It follows that efforts to increase school connectedness by engaging students and families in the school community can impact AOD use.10 A report from the Centers from Disease Control and Prevention provides a list of guidelines for increasing school connectedness that includes both curricular and logistical actions. These recommendations fall under 4 general categories: adult support, belonging to a positive peer network, commitment to education, and school environment (Box 1).7 Another element of school climate that affects initiation of AOD use is access to drugs on school grounds. In the 2009 Youth Risk Behavior Study, 23% of high school students reported that they had been offered drugs on school property. More robust efforts to define and enforce policies that establish school as a drug-free environment are associated with lower rates of use.11 In addition to these global strategies targeting the school environment, schools are ideal settings to implement universal, selective, and indicated prevention as well as SUD treatment. Universal Prevention of Substance Use and Other Risky Behaviors
Schools have been identified as an ideal setting for substance use prevention programs because they can be incorporated into the usual curriculum to reach large populations of youth before beliefs and expectations about AOD use have been firmly established. Beginning in elementary school, some programs targeting aggression and disruptive behaviors are effective in preventing multiple risky behaviors including initiation of substance use and prevention of SUD.12 A recent Cochrane (2011) review, however, concluded that only a small number of drug/alcohol prevention programs had sufficient empirical support for their efficacy.13 One example of such a program is the Good Behavior Game, a method of classroom behavior management used by teachers in first and second grade classrooms.14 The specific target of this intervention was to improve classroom socialization of children who displayed aggressive, disruptive behavior. Longitudinal follow-up of students in classrooms where teachers were randomized to receive Good Behavior Game training found significant decreases in SUD when the students were aged 19 to 21 years.15 The rate of lifetime SUD in
Box 1 Factors that can increase school connectedness Adult Support School staff can dedicate their time, interest, attention, and emotional support to students. Belonging to a Positive Peer Group A stable network of peers can improve student perceptions of school. Commitment to Education Believing that school is important to their future, and perceiving that the adults in school are invested in their education, can get students engaged in their own learning and involved in school activities. School Environment The physical environment and psychosocial climate can set the stage for positive student perceptions of school. From Centers for Disease Control and Prevention. School connectedness: Strategies for increasing protective factors among youth. Atlanta (GA): U.S. Department of Health and Human Services; 2009.
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males was significantly lower in those who were in Good Behavior Game classrooms (19%) compared with control classrooms (38%) and the decrease in risk was most pronounced for youth at greatest risk. Other interventions have been developed for middle school students to delay the onset of first substance use and prevent progression to SUD. These programs typically target sixth or seventh grade students who have not yet begun using AOD and focused on increasing knowledge about potential risks of AOD use, drug refusal skills, resistance to peer pressure, and improved decision making skills.16 Notably, even the best prevention interventions have only modest effect sizes that attenuate over time. Programs that engage students in active processes have been found to be more effective than didactic lecture-based programs. Indicated Prevention and Early Intervention for Mild to Moderate Substance Use
As noted, most adolescents who use substances do not meet criteria for clinical disorders; however, early interventions to reduce quantity and frequency of AOD use may prevent or delay progression to SUD. Several systematic reviews have examined brief interventions to address subclinical AOD use in adolescents.17,18 In general, early intervention can be effective in decreasing AOD-related harm, but the benefits may be short lived and the study design has a significant impact on results. For example, in a recent review of brief interventions delivered in schools, brief interventions were more effective than assessment only, but no more effective than a control condition that provided teens with information about substance use.17 Although brief interventions can be effective in decreasing harm in youth who do not meet diagnostic criteria for SUD, more intensive school-based motivational enhancement therapy (MET)/cognitive–behavioral therapy (CBT) interventions are needed for the estimated 10% to 15% of adolescents who have clinically significant patterns of AOD use. SCHOOL BASED SCREENING AND REFERRAL TO TREATMENT
Most youth who have SUD problems will not seek treatment, and youth who receive treatment in schools are even less likely than peers in clinic settings to recognize substance use as a problem or understand the need for treatment.19–21 Therefore, effective screening is essential to providing services that may prevent long-term consequences of disease. Screening Brief Intervention and Referral to Treatment (SBIRT) refers to a model for intervention that applies universal screening for all students and offers brief motivational enhancement to address mild to moderate problems. When more severe problems are identified, referral to more intensive treatment is indicated.22 Use of a formal screening instrument increases dramatically the likelihood of positive reports in multiple settings. In 1 study of pediatricians who screened for substance use in routine clinical care, a standard screening identified 100 youth with problem substance use and 86 who met full diagnostic criteria for SUD, whereas a clinical examination without a formal screening tool identified only 16 with problem use and 10 with a SUD.23 Many screening tools have been validated for use in adolescents and may be administered in school settings (Table 1). One convenient screening tool is the CRAFFT questionnaire that asks 6 yes or no questions regarding experience with AOD (Box 2).27 These questions screen for problematic AOD use and can be administered by any concerned adult. Adolescents who answer yes to any of these questions should undergo additional assessment of the frequency and quantity of use as well as negative consequences of AOD use. The additional information gathered in a clinical interview can guide decisions about referral for treatment to the
Substance Use Prevention and Intervention
Table 1 Evidence-based assessment for SUD Estimated Time No. of to Complete Items (min) Cost
Screening Instrument
Primary Focus
Adolescent Diagnostic Interview (ADI)
Comprehensive review of symptoms related to SUD
213
50
$75 per kit (includes 5 assessment booklets)
24
Adolescent Drug Involvement Scale (ADIS)
Developed as a research tool to distinguish heavy, problematic users from lower risk users
13
5
Free
25
Alcohol Use Disorders Identification Test (AUDIT)
Screening for problem alcohol use across health care settings
10
10
Free
26
CRAFFT
Screener to identify youth who require further assessment
6
MD
b
,
KEYWORDS Substance use disorder Adolescent School mental health KEY POINTS Schools provide an ideal setting for screening, brief interventions, and outpatient treatment of substance use disorders (SUD). Individual treatment for SUD is effective at decreasing substance use as well as substance-related harm. In some contexts, rather than being helpful, group interventions can result in harm to participants; therefore, individual treatment may be preferred. Early interventions for adolescents using alcohol and other drugs (AOD) are generally effective in decreasing frequency and quantity of AOD use and decreasing risky behaviors.
INTRODUCTION
Most youth who have mental health problems do not receive appropriate services. This treatment gap is especially pronounced for problems related to or co-occurring with substance use.1 In the United States, about 5% of youth aged 12 to 17 will develop a substance use disorder (SUD) each year, but fewer than 10% of the 1.3 million youth who meet diagnostic criteria for a SUD receive treatment.2 Many schools implement evidence-based drug/alcohol prevention programs; however, the vast majority of these programs target youth who have not yet initiated substance use. In the community, the vast majority of adolescents who receive treatment are mandated to receive care by juvenile justice. Treatment resources are extremely limited for the estimated 10% to 15% of high school students who regularly use or
a Division of Child and Adolescent Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA; b Division of Substance Dependence, School of Medicine, Mail Stop F478, 12469 East 17th Place, Building 400, Aurora, CO 80045, USA; c Center for School Mental Health, Division of Child and Adolescent Psychiatry, University of Maryland School of Medicine, 737 West Lombard Street, 426, Baltimore, MD 21201, USA * Corresponding author. E-mail address: [email protected]
Child Adolesc Psychiatric Clin N Am 24 (2015) 291–303 http://dx.doi.org/10.1016/j.chc.2014.12.004 childpsych.theclinics.com 1056-4993/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
292
Benningfield et al
Abbreviations ACRA AOD CBT CM CYT MDFT MET SUD
Adolescent Community Reinforcement Approach Alcohol and other drugs Cognitive–behavioral therapy Contingency management Cannabis Youth Treatment Multidimensional family therapy Motivational enhancement therapy Substance use disorder
meet diagnostic criteria for a SUD, but who are not (yet) involved with the juvenile justice system. Co-locating high-quality substance/behavioral health treatment in schools, including in school-based health centers, has the potential to improve screening, treatment access and availability, continuing care, and coordination of medical/behavioral health care.3 Compared with community-based treatment settings, youth who have access to school-based health centers are 10 times more likely to make a mental health or substance use visit and participate in screening for other high-risk behaviors.4 Implementing evidenced-based substance treatment interventions in schools also has the potential to reach youth at earlier stages of substance severity and to reduce the risk of progression to more chronic addiction with considerable cost savings to society.5 PREVALENCE OF SUBSTANCE USE IN ADOLESCENTS
The National Survey on Drug Use and Health found that 2.2 million youth ages 12 to 17 years reported using illicit drugs in the past month and 1.6 million youth reported binge drinking (consuming 4 or more drinks in 1 sitting for females or 5 or more drinks in 1 sitting for males) in the past month.2 Most youth who engage in substance use do not meet diagnostic criteria for clinical disorders; however, any substance use during adolescence is concerning because the risk for developing a SUD increases significantly with earlier age of initiation of use.6 For each year beyond age 14 that first alcohol use is delayed, the odds of subsequent alcohol use disorder drop by 14%. Lifetime prevalence of alcohol dependence was nearly 40% in those who reported first drinking alcohol before age 14 compared with about 10% in those who started drinking at age 20 or older.6 Thus, efforts to delay the initiation of substance use may significantly impact public health and dramatically decrease the cost to society of SUD. SCHOOL BASED PREVENTION OF SUBSTANCE USE DISORDERS School Climate and Connectedness
Connection with school has a bidirectional relationship with adolescent substance use. Youth who drop out of school have a significantly increased risk for cigarette, marijuana, and alcohol use and those who use alcohol and other drugs (AOD) are more likely to leave school.7 School connectedness is characterized by students having positive relationships with teachers, administrators, and peers at school and expressing a sense of commitment to the school. Connectedness is facilitated by provision of a safe learning environment where students feel they are treated fairly. Even in ideal circumstances, school connectedness often declines as youth enter middle school8—a time when rates of AOD use are on the rise. In a study of more than 2000 students, low school connectedness was associated with a 2-fold increase in regular alcohol
Substance Use Prevention and Intervention
drinking, cigarette smoking, and marijuana use.9 It follows that efforts to increase school connectedness by engaging students and families in the school community can impact AOD use.10 A report from the Centers from Disease Control and Prevention provides a list of guidelines for increasing school connectedness that includes both curricular and logistical actions. These recommendations fall under 4 general categories: adult support, belonging to a positive peer network, commitment to education, and school environment (Box 1).7 Another element of school climate that affects initiation of AOD use is access to drugs on school grounds. In the 2009 Youth Risk Behavior Study, 23% of high school students reported that they had been offered drugs on school property. More robust efforts to define and enforce policies that establish school as a drug-free environment are associated with lower rates of use.11 In addition to these global strategies targeting the school environment, schools are ideal settings to implement universal, selective, and indicated prevention as well as SUD treatment. Universal Prevention of Substance Use and Other Risky Behaviors
Schools have been identified as an ideal setting for substance use prevention programs because they can be incorporated into the usual curriculum to reach large populations of youth before beliefs and expectations about AOD use have been firmly established. Beginning in elementary school, some programs targeting aggression and disruptive behaviors are effective in preventing multiple risky behaviors including initiation of substance use and prevention of SUD.12 A recent Cochrane (2011) review, however, concluded that only a small number of drug/alcohol prevention programs had sufficient empirical support for their efficacy.13 One example of such a program is the Good Behavior Game, a method of classroom behavior management used by teachers in first and second grade classrooms.14 The specific target of this intervention was to improve classroom socialization of children who displayed aggressive, disruptive behavior. Longitudinal follow-up of students in classrooms where teachers were randomized to receive Good Behavior Game training found significant decreases in SUD when the students were aged 19 to 21 years.15 The rate of lifetime SUD in
Box 1 Factors that can increase school connectedness Adult Support School staff can dedicate their time, interest, attention, and emotional support to students. Belonging to a Positive Peer Group A stable network of peers can improve student perceptions of school. Commitment to Education Believing that school is important to their future, and perceiving that the adults in school are invested in their education, can get students engaged in their own learning and involved in school activities. School Environment The physical environment and psychosocial climate can set the stage for positive student perceptions of school. From Centers for Disease Control and Prevention. School connectedness: Strategies for increasing protective factors among youth. Atlanta (GA): U.S. Department of Health and Human Services; 2009.
293
294
Benningfield et al
males was significantly lower in those who were in Good Behavior Game classrooms (19%) compared with control classrooms (38%) and the decrease in risk was most pronounced for youth at greatest risk. Other interventions have been developed for middle school students to delay the onset of first substance use and prevent progression to SUD. These programs typically target sixth or seventh grade students who have not yet begun using AOD and focused on increasing knowledge about potential risks of AOD use, drug refusal skills, resistance to peer pressure, and improved decision making skills.16 Notably, even the best prevention interventions have only modest effect sizes that attenuate over time. Programs that engage students in active processes have been found to be more effective than didactic lecture-based programs. Indicated Prevention and Early Intervention for Mild to Moderate Substance Use
As noted, most adolescents who use substances do not meet criteria for clinical disorders; however, early interventions to reduce quantity and frequency of AOD use may prevent or delay progression to SUD. Several systematic reviews have examined brief interventions to address subclinical AOD use in adolescents.17,18 In general, early intervention can be effective in decreasing AOD-related harm, but the benefits may be short lived and the study design has a significant impact on results. For example, in a recent review of brief interventions delivered in schools, brief interventions were more effective than assessment only, but no more effective than a control condition that provided teens with information about substance use.17 Although brief interventions can be effective in decreasing harm in youth who do not meet diagnostic criteria for SUD, more intensive school-based motivational enhancement therapy (MET)/cognitive–behavioral therapy (CBT) interventions are needed for the estimated 10% to 15% of adolescents who have clinically significant patterns of AOD use. SCHOOL BASED SCREENING AND REFERRAL TO TREATMENT
Most youth who have SUD problems will not seek treatment, and youth who receive treatment in schools are even less likely than peers in clinic settings to recognize substance use as a problem or understand the need for treatment.19–21 Therefore, effective screening is essential to providing services that may prevent long-term consequences of disease. Screening Brief Intervention and Referral to Treatment (SBIRT) refers to a model for intervention that applies universal screening for all students and offers brief motivational enhancement to address mild to moderate problems. When more severe problems are identified, referral to more intensive treatment is indicated.22 Use of a formal screening instrument increases dramatically the likelihood of positive reports in multiple settings. In 1 study of pediatricians who screened for substance use in routine clinical care, a standard screening identified 100 youth with problem substance use and 86 who met full diagnostic criteria for SUD, whereas a clinical examination without a formal screening tool identified only 16 with problem use and 10 with a SUD.23 Many screening tools have been validated for use in adolescents and may be administered in school settings (Table 1). One convenient screening tool is the CRAFFT questionnaire that asks 6 yes or no questions regarding experience with AOD (Box 2).27 These questions screen for problematic AOD use and can be administered by any concerned adult. Adolescents who answer yes to any of these questions should undergo additional assessment of the frequency and quantity of use as well as negative consequences of AOD use. The additional information gathered in a clinical interview can guide decisions about referral for treatment to the
Substance Use Prevention and Intervention
Table 1 Evidence-based assessment for SUD Estimated Time No. of to Complete Items (min) Cost
Screening Instrument
Primary Focus
Adolescent Diagnostic Interview (ADI)
Comprehensive review of symptoms related to SUD
213
50
$75 per kit (includes 5 assessment booklets)
24
Adolescent Drug Involvement Scale (ADIS)
Developed as a research tool to distinguish heavy, problematic users from lower risk users
13
5
Free
25
Alcohol Use Disorders Identification Test (AUDIT)
Screening for problem alcohol use across health care settings
10
10
Free
26
CRAFFT
Screener to identify youth who require further assessment
6
