The efficacy of a systematic substance abuse program for adolescent females.

A school-based substance abuse prevention program based on the assumptions of the ASCA National Model[R] was designed to change adolescent females' drug-using behaviors. The program was designed to reduce substance abuse, increase negative attitudes toward drug use, and reduce negative behaviors while increasing positive behaviors, knowledge of the physical symptoms of drug use, student achievement, and self-esteem. Group sessions were based on solution-focused brief therapy and action learning theory and were supplemented by mentorship from community members and peers. Positive outcomes were found on five-dependent variables.

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Research supporting the efficacy of comprehensive school guidance and counseling programs based on the assumptions of the ASCA National Model[R] is scarce (Brown & Trusty, 2005a, 2005b; Carey, Harrity, & Dimmitt, 2005). However, if supported by research, such school-based programs may provide a vehicle to prevent substance abuse and promote social competence among adolescent females. This article describes an experimental study that evaluated the impact of a school-based drug prevention program based on the premises of the ASCA National Model (American School Counselor Association, 2005) on eighth-grade girls' attitudes about drug use, actual drug use, knowledge of the symptoms of drug abuse, academic achievement, self-esteem, and behavior at school and home.

The program evaluated in this study was the "SAM" (solution, action, mentorship) program, which was named for the basic program components: group solution-focused brief therapy, action learning techniques, and mentorship. This program helped students to make positive decisions and effectively manage normal developmental tasks (as advocated in the ASCA National Model, 2005) by incorporating solution-focused brief therapy strategies such as finding exceptions, asking the miracle question, and scaling (de Shazer, 1988; Metcalf, 1995) with the interactive games and activities found in action learning (Jackson, 1995) and peer and community mentorship. Mentorship was provided through monthly group lessons and interactions conducted by trained high school peers or community Mexican American businesswomen.

This psychoeducational group counseling program was designed and implemented by one of the researchers (a practicing school counselor) to offer outcome data on a school counseling program designed for females. The program was based on the ASCA National Model's (2005) preventative and developmental orientation design. The incorporation of small group counseling for normal developmental tasks (as suggested by the ASCA National Model) was intended to help female students "identify problems, causes, alternatives and possible consequences so they can take appropriate action" (ASCA, 2005, p. 42).

RELEVANT TRENDS

School counselors are encouraged to show accountability through outcome data (Webb, Brigman, & Campbell, 2005; Whiston, 2002; Whiston & Sexton, 1998). Since drug use among girls is equal to or surpassing that of males (Center on Alcohol Marketing and Youth, 2004; Hanson, 2002; Ketcham & Pace, 2003; Najavits, 2002; Substance Abuse and Mental Health Services Administration, 2002; Tait, 2005) and has been linked to negative behaviors and low academic achievement (Brook & Cohen, 1998), school-based drug prevention/intervention programs targeting adolescent females also may provide educational benefit to participants.

Despite the possibility that such programs might provide academic and social benefits to female students, few drug prevention and intervention studies have focused on outcomes for females (Blake, Amaro, Schwartz, & Flinchbaugh, 2001; Blumenthai, 1998; Goldberg, 2002; Kandall, 1998; Najavits, 2002; Pinn, 1998; Substance Abuse and Mental Health Services Administration, 1997). Programs specifically designed for females might heighten counselor accountability while assisting female students through age-appropriate developmental issues such as drug use, attitudes toward drug use, knowledge levels, self-esteem, behavioral issues, and academics.

TREATMENT RATIONALE

The SAM program was based on several theoretical approaches: Erikson's (1968) identity formation theory, social influence theory, competence enhancement, science-based prevention (teaching the consequences of drug abuse; Botvin, 2000), experiential techniques (through action learning; Jackson, 1995), social learning (incorporated through mentorship and parent involvement; Bandura, 1986), and cognitive and behaviorally based strategies (as infused into solution-focused brief therapy; Botvin, Baker, Dusenbury, Tortu, & Botvin, 1990). The open nature of the group solution-focused brief therapy sessions left room for each technique above while offering an effective and easily implemented intervention (LaFountain & Garner, 1996).

For ethical reasons, the researchers included as many research-proven techniques in the program as possible. Research has shown that effective drug prevention programs include the following aspects: reducing risk factors and enhancing protective factors, targeting multiple drugs, the incorporation of developmental and cultural factors, interactive teaching methods, peer mentorships, and community involvement (Bosworth, 1997; Dusenbury & Falco, 1995; Pentz, 2003). The multifaceted program combined several components such that all aforementioned strategies were included in the program.

PURPOSE OF THIS STUDY

The researchers investigated the impact of a school-based drug prevention program focusing on the dynamics of drug use, behavior, knowledge levels, academics, and self-esteem. It was hypothesized that eighth-grade girls involved in a group counseling program involving solution-focused brief therapy, peer and community mentorship, and action learning techniques would experience decreased drug use, development of more negative attitudes toward drug use, increased knowledge of drugs and the effects of drug use, improved behavior at school and home, higher grades, and increased self-esteem. These hypotheses were examined using quantitative methodology.

METHOD

Participants

A diverse population of eighth-grade females self-reporting nonparticipation in drug prevention or counseling programs was selected from an urban middle school. Random selection was used to select participants from the target population. Each eighth-grade female in the school population had her name placed in a jar and drawn such that every other name was alternately assigned to experimental and control groups. Forty students were selected for the experimental group with a second 40 students designated as a control group.

Random assignment procedures resulted in two groups that were matched based on ethnicity and socioeconomic background while reflective of the original population. The school's overall population consisted of approximately 308 eighth graders, 280 seventh graders, and 280 sixth graders. Of this group, 45% were female. The student population consisted of 32% Anglo, 58% Mexican American, 6% African American, and less than 1% American Indian students.

Of the 40 original participants selected as the treatment group, 22 were Mexican American, 2 were African American, and 16 were Anglo. The control group consisted of 21 Mexican American, 3 African American, and 16 Anglo females. Of these original participants, 8 students in the treatment group and 7 in the control group dropped from the study prior to completion. Fifty percent of those in the treatment group and 52.5% of those in the control group were eligible for the school's free or reduced lunch program.

Additional information on methodology can be obtained from the first author.

Instruments

A total of six instruments were administered to participants, teachers, or parents in August (pretest) and again in December (posttest). Information on each assessment follows.

The American Drug and Alcohol Survey (ADAS) was used to measure student self-reported drug use. This instrument was developed to assess and compare student drug use within various populations, including schools (Rocky Mountain Behavioral Science Institute [RMBSI], 2003). The ADAS consists of questions about the amount (ranging from no use to several times a week) of drug use. Questions with Likert-response choices assess the frequency of use of 14 substances (alcohol, tobacco, marijuana, cocaine, inhalants, uppers, downers, heroin, LSD, PCP, Ritalin, narcotics, ketamine, and ecstasy).

Research with the ADAS found Cronbach's alpha reliability statistics ranging from .72 to .93 for females (RMBSI, 2003). Concurrent validity has been found when comparing the instrument to the National Monitoring the Future Survey (RMBSI).

The Substance Abuse Subtle Screening Inventory Adolescent Version 2 (SASSI-A2) Attitude scale was used to measured student attitudes toward drug use. Miller, Renn, and Lazowski (2001) developed the SASSI-A2 to screen adolescents between the ages of 12 and 18 for drug use and/or dependence. The SASSI-A2 Attitude scale consists of 10 true/false questions implying either a non-accepting attitude toward drug use (scored 0) or a permissive attitude toward drug use (scored 1 point). Higher scores on the SASSI-A2 Attitude scale have been shown to indicate defensive behaviors when confronted about drug abuse (Miller et al.). The 72-item assessment has been found to be accurate in identifying both substance dependence and substance abuse disorders 94% of the time (Miller et al.).

Further, research with the instrument indicates it distinguishes those without a disorder 89% of the time as compared to those previously diagnosed by practitioners using the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Miller & Lazowski, 2001). Validation studies with the SASSI A-2 have found a kappa statistic of .78, suggesting adequate validity (Miller et al., 2001). The Attitude scale reports an alpha coefficient of .76 and a test-retest coefficient (conducted over a 2-week interval) of .92 (Miller & Lazowski).

A researcher-constructed knowledge exam was designed to measure knowledge related to the physical symptoms of drug use. Thirty-three multiple-choice questions asked participants questions about the consequences of using cocaine, LSD, methamphetamines, inhalants, marijuana, alcohol, tobacco, and crack. For example, one question stated, "Smokeless tobacco can cause the following health problems." Choices included cancer of the lungs, emphysema, cancer of the mouth and esophagus, or none of the above. One point was assigned for each correct item and summed creating a total score.

The knowledge exam was normed by the researchers in the spring of 2004 using 50 eighth-grade females from the same school as that attended by the participants of this study. Correlations across multiple measurements ranged from .87 to .93. Test-retest coefficients taken over a 28-day interval yielded a correlation of .90.

The Piers-Harris Children's Self-Concept Scale, Version 2 (PHCSCS-2) measured participants' self-esteem. The PHCSCS-2 was developed to evaluate students for educational and clinical placement (Piers & Herzberg, 2002). The current revision of the Piers-Harris consists of 60 items written at a second-grade reading level and intended for use by students in grades 2 through 12 (Piers & Herzberg). The 60 items are categorized into six domain scales (Behavioral Adjustment, Intellectual and School Status, Physical Appearance and Attributes, Freedom from Anxiety, Popularity, and Happiness and Satisfaction) that assess separate aspects of self-esteem.

High reliability estimates have been reported for the PHCSCS-2 (Piers & Herzberg, 2002). Coefficient alpha values taken when comparing the revised version with the original instrument were .93 and .91 (Piers & Herzberg). The two aforementioned instruments correlate at .98. Reliability coefficients for the six domain scales ranged from .75 to .81 (Piers & Herzberg).

The Home and Community Social Behavior Scales (HCSBS) social competence scale was used to measure parent-observed social behaviors. The HCSBS was developed for use with students between the ages of 5 and 18 and is intended to identify student antisocial and socially competent behaviors within the home setting (Merrell & Caldarella, 2002). The HCSBS exhibits high reliability and validity (Merrell & Caldarella). It was normed using 1,562 cases randomly selected from a larger population such that ethnicity, socioeconomic status, gender, and educational classification were consistent with population values as based on 2000 U.S. Census data. Participants in the normative sample represented nine states and 13 communities. Internal consistency reliabilities ranged from .91 to .97 and .82 to .91 for test-retest correlations taken at a 1-week interval. Interrater reliabilities ranged from .64 to .86 (Merrell & Caldarella).

The School Social Behavior Scales, Second Edition (SSBS-2) social competence scale was used to measure teacher-observed social behaviors. The SSBS-2 was developed for use with students between the ages of 5 and 18 and is intended to identify student antisocial and socially competent behaviors within the school setting (Merrell & Caldarella, 2002). The normative sample used for the SSBS-2 consisted of 2,280 students in kindergarten through 12th grade representing 20 states and the four major geographical regions of the country. Regular education teachers made up 86% of the total population of raters, special education teachers formed 13%, and other educational professionals such as administrators or school counselors accounted for 1% of the total ratings. Measures of reliability and validity indicate the SSBS-2 is highly consistent and tests the purpose intended (Merrell & Caldarella). Test-retest correlations taken at a 1-week interval ranged between .86 and .94 while 3-week interval ratings yielded correlations between .60 and .83 (Merrell & Caldarella). Interrater reliability correlations fell between .53 and .71, and convergent and discriminate validity studies support adequate validity of the SSBS-2 (Merrell & Caldarella).

Research Design

A pretest-posttest control group experimental design was utilized with subjects randomly selected and assigned to groups. Dependent variables consisted of scores on each of the six measures (ADAS, SASSI-A2, PHCSCS-2, HCSBS, SSBS-2, and the knowledge exam), cumulative grade point averages, and number of office referrals. Pretests were used as covariates to equalize initial differences between groups. The independent variable was participation in the SAM program.

The relationship between program participation and the eight dependent measures was tested using multivariate analysis of covariance and preplanned univariate analysis of covariance as follow-up comparisons. The posttest means were compared for students in the treatment and control groups and all findings were tested using an alpha level of .05.

Procedure

The SAM program consisted of an integration of group solution-focused brief therapy techniques (de Shazer, 1988; Metcalf, 1995), action learning techniques (Jackson, 1995), and community and peer mentorship. Weekly 1-hour group sessions with seven or eight students were implemented for 16 weeks. Additionally, the school counselor conducted two parent meetings (one prior to the first student meeting and one at the conclusion of the program). The overall design of each student session consisted of action learning lessons (Jackson), discussions, and guest speakers followed by private (school counselor and students only) group solution-focused brief therapy sessions using Metcalf's model.

One school counselor, five Mexican American community mentors, and three high school seniors (two female and one male) led the group sessions and guidance lessons. The school counselor facilitated and conducted solution-focused brief therapy group sessions each week for 16 weeks and was present during each guidance lesson conducted by mentors. Of the 16 guidance lessons, one was taught by high school students, four by community mentors, and the remaining lessons were taught by the school counselor. After lessons were taught, mentors exited sessions leaving only the participants and school counselor present for group counseling sessions. This arrangement helped maintain the confidentiality of sessions and left a trained professional to handle multicultural and ethical issues related to small group counseling. Parents participated in two meetings (one prior to program implementation and one at the conclusion of the program) that were conducted by the school counselor.

The planned interactive group lessons focused on issues related to developmental identity formation (Erikson, 1968). For example, topics such as goal setting, career exploration, drug information, peer-pressure resistance, decision making, and relationships were discussed weekly. Solution-focused brief therapy sessions were conducted by the school counselor (without the presence of mentors) and followed the aforementioned lessons. These sessions were spontaneous allowing the incorporation of material unique to each participant.

Community and high school mentors were selected in conjunction with district staff. Criteria for selection of the community mentors included attendance at two counselor-led training sessions, passing a criminal background check conducted by district administration, current success in educational or professional endeavors (including current employment and/or advanced degrees), recommendation by a district employee, and the desire to assist adolescent girls.

Each community mentor attended two training sessions conducted by the school counselor. Trainings focused on the delivery of specific interactive lessons, counseling techniques including active listening and empathy, and developmental issues such as identity versus identity confusion (Erikson, 1968).

High school student mentors were selected based on recommendations by teachers, high school counselors, and other trusted students. Criteria for high school student mentor selection included recommendation by two high school staff members, recommendation by the middle school counselor and principal, attendance at three training sessions, recommendation by 20 other students as being non-drug-using teens, and the willingness to assist middle school girls.

High school student trainings consisted of rehearsing lessons, providing factual information on drug use and proper responses to questions, discussing the importance of congruence of message and lifestyle, and instruction in peer-pressure resistance strategies.

The school principal and district administrative staff supported implementation of this program and study. The researcher, a school counselor, designed the program such that the treatment group participated in the program during the fall semester and then replicated it for control group members after the completion of the study. School administrators approved this schedule prior to program implementation.

Parents were notified of the program and study through phone calls and informed consent letters. Students were required to have written parental consent before participation in either the control or experimental groups. For ethical reasons, parents were informed as to the group (control or treatment) their child had been assigned, and all participants agreed to participation.

Students in the control group were not exposed to treatment during the study and teachers were unaware as to which students were designated as treatment subjects. After completion of the study, control group students received the program.

A total of six instruments were administered to participants, teachers, or parents. Four instruments were administered to students including the ADAS, SASSI-A2, PHCSCS-2, and knowledge exam. Additionally, the researchers collected data on grade point averages and number of teacher-written office referrals for each participant prior to and following the treatment.

Assessments were completed anonymously using a code previously given to students by a school staff member. The staff member was not present during test administration or given access to assessments and the researcher was not privy to student codes. Codes were destroyed after the posttest was given. Thus, anonymity was maintained.

RESULTS

This study examined the effects of an intervention incorporating group solution-focused brief therapy sessions, action learning techniques, and mentorship on eighth-grade females' drug use, attitudes toward drug use, knowledge of the physical consequences of drug use, social behaviors, self-esteem, and grades.

To determine significance, a multivariate analysis of covariance (MANCOVA) was conducted using pretests as a covariate, group membership (placement in control or experimental groups) as the factor variable, and scores on the eight posttest scales as the dependent variables. The MANCOVA revealed a significant interaction of group (as measured by an alpha level of .05 for all statistics) on the combined dependent variables (p = .0001).

Univariate statistics (ANCOVAs) were run as a follow-up to determine which of the eight dependent variables were significantly related to group participation. As shown in Table 1, significance was found between treatment and control groups in the areas of drug use (F = 12.55, p < .001), attitudes toward drug use (F = 12.86, p < .001), knowledge (F = 36.45, p < .001), and teacher- (F = 15.28, p < .001) and parent-rated competent behavior scores (F = 15.28, p < .001). Significant differences were not found with regard to self-esteem (F = .64, p < .428), negative behaviors (F = 2.48, p < .123), and grade point averages (F = 2.51, p < .121).

Table 1 illustrates pretest and posttest treatment and comparison means and standard deviations for each dependent variable.

DISCUSSION

The objective of this study was to determine the outcome of a counseling intervention on adolescent girls' drug use, attitudes toward drug use, behaviors, self-esteem, knowledge, and grades. Results indicate that participation in the intervention was associated with decreased drug use, less favorable attitudes toward drug use, increased socially competent behaviors, and an increase in the knowledge of consequences of drug use as compared to the control group. Mean differences and standard deviations for each dependent variable are listed in Table 1.

Conclusions of this study support the implementation of school-based counseling programs addressing female drug use and behavioral issues. Results were consistent with other successful school-based programs. For example, Botvin's (1996) research with the Life Skills Training Program and social influence approach suggests that drug use and accompanying behavioral issues can be prevented by targeting students' social and psychological needs (Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995; Botvin et al., 1990). The incorporation of a social component (mentorship, peer interactions, group sessions) along with psychological factors (solution-focused brief therapy) further supports Botvin's approach and inclusion of such social and psychological program components. AS such, best results may be obtained with programs consisting of multiple components that address identity formation (including attitudes), social issues (including competent behaviors and peer interactions), family factors, risk and protective factors, psychological needs, and background issues such as culture and gender.

Dusenbury and Falco (1995) have contended that interactive teaching methods are superior to didactic methods when working with adolescents in drug prevention programs. Adolescents may require active involvement, and inclusion of this type of involvement may lead to increased learning. Increased knowledge levels among treatment group members in this study give credence to the implementation of such interactive methods, specifically action learning techniques. It is our contention that school counselors may achieve optimal results when using active rather than passive teaching methods.

The developmental nature of the treatment used in this study supports the use of group universal prevention interventions targeted to reach all students of a particular age within a particular setting. AS such, universal prevention programs targeting all students (as suggested in the ASCA National Model, 2005) are given credence.

Further research is needed to determine whether counseling programs change academic outcomes, negative student behaviors, and self-esteem. While grades did improve slightly for the experimental group (as compared to the control group), significance was not found. Several factors may influence grades, including teaching styles, parent participation, maturation, and a number of other possibilities. With regard to office referrals, it is noted that many of the students did not have any office referrals during pretesting. Further, much variance was noted between infractions on office referrals. This variance may have made significance difficult to obtain. Perhaps studies conducted over a longer term are necessary to influence multifaceted variables.

Implications for School Counselors

The findings of this study support prior research (Botvin et al., 1995; Botvin et al., 1990; Dusenbury & Falco, 1995; LaFountain & Garner, 1996) that advocates the use of certain strategies in drug prevention. Specific implications of these results support the use of group solution-focused brief therapy, peer and community mentorship, and interactive teaching methods by school counselors. Data indicating an increase in drug use among control group members reveal the importance of implementing a drug prevention and intervention curriculum for all eighth-grade females that includes counseling as part of the program.

This study gives credence to the fact that all female students can benefit from school counseling programs and offers a possible focus when planning comprehensive guidance and counseling programs. The ASCA National Model (2005) advocates the implementation of comprehensive guidance programs that target all students. The apparent correlations shown among knowledge levels, attitudes toward drug use, social behaviors, and drug use imply that these might be appropriate areas of focus when developing effective programs. The positive relationship between program participation and increased social competence found in this study might indicate a stronger connection between increasing positive behaviors (as opposed to decreasing negative behaviors) and drug use prevention. As such, school counselors might focus on enhancing positive social behaviors instead of focusing on a change in negative outbursts.

Limitations

Limitations are unavoidable when conducting a study using human participants. Although students were randomly selected and assigned, all attended a single school. As such, participants may not necessarily be representative of the national population and generalizations may not be appropriate to all settings. Replications of the study would strengthen support for the intervention. Also, the study was limited to only female participants. As such, generalizations to males may be inappropriate.

Lesson facilitators were trained such that information was disseminated in a similar manner. Nonetheless, assurances cannot be given that all lessons were taught in a perfectly identical manner.

Finally, the administration of a pretest often causes concerns with pretest-treatment interactions. Guarantees cannot be made that changes were made solely as a result of the treatment. Often, students learn by taking a pretest and results can only be generalized to other pretested groups.

Conclusion

Outcome studies are needed to determine the efficacy of school counseling programs (Whiston & Sexton, 1998). This evaluation of the SAM program contributes to the research literature while offering school counselors a program that coincides with recommendations in the ASCA National Model. The SAM program shows promise in preventing drug use, increasing socially competent behaviors that impact learning and knowledge of the consequences of drug use, while decreasing positive attitudes toward drug use.

References

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Janet G. Froeschle is an assistant professor of counselor education at West Texas A&M University. E-mail: [e-mail] Robert L. Smith and Richard Ricard are professors at Texas A&M University-Corpus Christi.

Table 1. Pre- and Posttest Treatment and Comparison Means
and Standard Deviations for Experimental and Control
Groups on Dependent Variables

Scale       Group            N     Pretest      SD
                                     Mean

ADAS        Experimental    30       3.8       6.58
ADAS        Control         31       3.19      6.28
SASSI-A2    Experimental    31       2.40      1.17
SASSI-A2    Control         33       2.91      1.86
Knowledge   Experimental    30      19.53      3.80
Knowledge   Control         31      19.87     -3.49
PHCSCS-2    Experimental    32      44.03      9.70
PHCSCS-2    Control         31      45.94      8.22
Referrals   Experimental    31       .48       1.24
Referrals   Control         32       .47       1.22
SSBS-2      Experimental    30      129.87    25.47
SSBS-2      Control         31      133.19    28.25
HCSBS       Experimental    30      130.03    25.38
HCSBS       Control         33      131.15    20.92
GPA         Experimental    32       3.34      .62
GPA         Control         32       3.32      .61

Scale         Posttest      SD     Adjusted     P
                Mean               Posttest
                                     Mean

ADAS            1.38       3.32      1.12     .001 *
ADAS            5.00       7.69      5.29
SASSI-A2        1.58       1.14      1.61     .001 *
SASSI-A2        3.04       1.81      3.01
Knowledge      25.27       3.16     25.12     .001 *
Knowledge      18.92       4.89     19.08
PHCSCS-2       47.35       7.52     47.04      .428
PHCSCS-2       47.96       8.09     48.29
Referrals       .12         .43      .14       .123
Referrals       .46        1.22      .44
SSBS-2         145.04      17.25    144.95    .001 *
SSBS-2         116.71      42.38    116.81
HCSBS          146.15      14.96    147.20    .001 *
HCSBS          131.00      19.38    129.87
GPA             3.56        .48      3.52      .121
GPA             3.34        .65      3.38

Note. p values are ANCOVA comparisons of treatment and control groups.

* p [less than or equal to] .006 (based on Bonferroni correction):