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Substance Abuse: Treating the Addicted Teen Client
RRS (Refusal & Resistance Skills) training is critically evaluated across different target behaviors and outcomes. RRS efficacy is considered for tobacco use, including smoking and smokeless tobacco, alcohol and substance abuse, and sexual activity. Factors that influence RRS training are identified and process variables are discussed. These include age and gender, media formats (video or live), and teacher-led versus peer-led approaches. Conclusions are drawn based on the reviewed literature.
Every year millions of dollars are provided to school systems across the United States to implement prevention and intervention programs, most of which are funded through the U.S. Department of Education (Dryfoos, 1993), the Department of Health and Human Services (e.g., the Substance Abuse and Mental Health Services Administration, the Center for Disease Control and Prevention), the juvenile justice system, and various state programs in the attempt to effect prosocial change in children and adolescents. In recent years, programs that teach refusal and resistance skills (RRS) have emerged as widely popular strategies, and funding is continually sought for the development and sustainment of such programs. But amid the variation of programs that exist, what do we really know about their efficacy? Do RRS programs produce substantive treatment effects? Is the literature uniformly supportive across different RRS programs?
Like other prevention efforts, RRS strategies vary considerably in their content and the way they are applied, making comparisons across programs inherently difficult. Sussman et al. (1993) differentiated between normative influence RRS programs (those that target pressure applied by a peer group) and informational influence RRS programs (those that target more covert pressures designed to influence behavior, such as media advertising). To complicate matters further, risky behaviors to which RRS are applied also vary considerably, but most frequently include smoking, alcohol use, illegal substance abuse, and sexual activity. Because RRS are often embedded as single segments within larger programs designed to address specific risk behaviors, conclusively identifying RRS components as either effective or ineffective is arduous. Nevertheless, RRS training has remained consistently popular among counselors, educators, and prevention specialists, and considerable research has examined RRS merits. Thus, the question is posed: "What general conclusions can be drawn from this literature?"
Through a search of the American Psychological Association PsycLIT CD-ROM database from January 1974 to November 1994 under the topic headings (refusal skills or resistance skills or just say no and adolescent or adolescence or child*), a total of 41 articles were identified. Through a search of the ERIC CD-ROM database from January 1982 to September 1994 under the same topic headings, 29 articles were identified. A considerable but not complete overlap of information was generated from each of these respective databanks. On the basis of our aforementioned selection criteria, 30 of these articles were grouped for discussion in this review, and 3 additional articles identified from the references of the original 30 were also included. Occasionally, articles outside of this select subset also are discussed for descriptive purposes. Thus, following a brief historical overview, the highlights of this body of work are summarized, and relevant conclusions based on this literature are drawn.
Alcohol and Other Drug Abuse
Most prevention programs adopted by schools attempt to educate students about the consequences of alcohol and other substances; however, there is some evidence that indicates that providing certain kinds of information (like what a drug or alcoholic beverage looks and smells like) might actually promote experimentation and use (Hansen et al., 1988). Purely educational approaches have not been particularly successful at reducing alcohol and drug use among young people (Hewitt, 1982). It is clear that more innovative prevention and intervention approaches are needed. Do RRS techniques represent such innovative approaches?
Shope, Copeland, Maharg, Dielman, and Butchart (1993) assessed students' ability to refuse alcohol and investigated relationships between refusal skill and measures of knowledge, alcohol-related intrapersonal characteristics, and self-reported alcohol use. Students with better refusal skills had higher levels of alcohol knowledge, less susceptibility to peer pressure, greater internal health locus of control and self-esteem, and less alcohol use and misuse. Although correlations between variables were small, results provided modest support for teaching RRS in substance abuse prevention programs (Shope et al., 1993).
Rohrbach et al. (1987) compared the effectiveness of RRS training against two competing alcohol prevention modalities. Elementary and middle school-age students were assigned to one of three treatment conditions (an RRS condition, an information condition, or a normative education condition). Students were assessed by way of a "multitrait-multimethod" assessment procedure that involved refusal self-efficacy and alcohol refusal skills, which combined self-reported information and behavioral responses to a role-play beer offer. Alcohol refusal skills were measured by three different raters (an adult data collector, a student observer, and the student himself/herself) on three different dimensions (the quality of refusal, the content of responses, and "self-efficacy"). RRS training significantly increased participants' ability to refuse alcohol and enhanced refusal self-efficacy when compared with the other competing prevention modalities.
Corbin, Jones, and Schulman (1993) compared two drug RRS strategies, one that incorporated elaborate rehearsal training and one that did not. Third graders were randomly assigned to one of three groups: a control group (in which students received drug education only), a general information group (in which students were taught drug knowledge, assertiveness skills, decision-making skills, and specific drug-refusal skills), and a rehearsal-plus group (in which students were taught the same information as the general information group but also were given a rationale for the information they received). Students in the rehearsal-plus group were exposed to four additional training steps: (a) Questions requesting reasons for performing each step in sequence were asked, (b) explanations for correct responses were provided, (c) students were asked to repeat correct rationales, and (d) students were encouraged to ask additional questions. Both the general and rehearsal-plus groups were exposed to RRS training. Students in the rehearsal-plus condition demonstrated significantly more effective behavioral skills, improved their decision-making skills, and demonstrated a better understanding of skill rationale. In other words, students who were taught to act in a specifically ordered sequence, and who were provided a rationale for doing so, outperformed their counterparts on several important domains. Similar support of rehearsal-plus training has been reported elsewhere (e.g., Jones, McDonald, Fiore, Arrington, & Randall, 1990).
Hansen et al. (1988) compared three alcohol prevention curricula: one that focused on teaching RRS, one that focused on solidifying conservative group norms, and one that sought to increase student awareness of the consequences of using alcohol. Students who received RRS training (i.e., demonstration, rehearsal, and role play of skills) were significantly more knowledgeable of social pressures and resistance methods. However, when confidence in students' ability to say no was assessed, no significant differences were found between conditions. Thus, although RRS training increased students' repertoire of effective ways to avoid offers, it was not successful in increasing their actual ability to do so. In addition, students who received the normative education curriculum had a greater awareness of conservative school norms, and students who received the information about consequences knew more about the consequences of drinking.
Ennett et al. (1994) reported on DARE (Drug Abuse Resistance Education), a nationally recognized drug abuse prevention program comprising a 17-session core curriculum based on a social influence prevention approach. Program emphasis is placed on enhancing general social competencies and skills needed to resist various forms of social pressure. Results indicated that DARE had only a limited effect on students' self-reported drug use at posttest, with no discernible effect at either a 1- or 2-year follow-up. Moreover, DARE training had virtually no effect on social variables such as peer-resistance skills.
Kim et al. (1989) evaluated the efficacy of the RRS program "WHOA! A Great Way To Say No" with a group of seventh-grade students. This three-session program was developed to help students learn specific skills for saying no to alcohol, drugs, and other substances and teaches strategies for dealing with high pressure. Several steps are practiced through role-play scenarios until participants "gain confidence in their ability to stand up for themselves and affirm what they believe in" (p. 364). A pre- and posttest design (with control group) revealed no statistically significant differences on drug attitude, social attitude, rebelliousness, and self-esteem. Moreover, a significantly larger proportion of experimental group students reported that it was more difficult for them to say "no" at posttest than at pretest, indicating that the RRS training may have sensitized students to the issue of saying no. In other words, students "seem to have become more conscious about the implications and complexities involved in saying 'no', leading them to think that there are more complex issues involved" (p. 369).
Finally, in a study that evaluated differences between African American and White youths who drink heavily, Ringwalt and Palmer (1990) found that White students rated disapproval from friends and peers as important reasons not to drink, whereas African American students rated the disapproval from adults as being more important. In a somewhat related finding, Giordano, Cernkovich, and DeMaris (1993) reported that for over 900 adolescents interviewed, African American students reported being more likely to maintain intimate relationships with family and relatives than with peers or friends. Taken together, these findings seem to suggest that peer-group influence may be less of a mediating variable for some African American youths than for their White counterparts, especially with regard to issues related to alcohol refusal. As such, consideration of such differences may be important when developing persuasion-resistant components of RRS programs.
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