Revisiting D.A.R.E.: A Critique with a Scientific Basis- Natalie Vena

Introduction

Drug abuse in the United States has been and continues to be an enormous public health burden. This problem is particularly concerning when it involves child and adolescence tobacco, alcohol and drug use. It is a leading cause for morbidity and has been linked to many chronic health conditions and diseases, such as cancer and cardiovascular disease. One in four deaths in the United States can be attributed to tobacco, alcohol or illicit drug use and abuse. In 2009, drug related incidences accounted for 4.6 million emergency room visits, with 19% of them involving children or adolescence under the age of 20 (1). One in five youths reported having friends that used cigarettes, one in four reported having friends who drank alcohol, and 42% reported having friends who smoked marijuana (2,3). Because tobacco, alcohol and illicit drug use among adolescence is a tremendous public health concern, significant efforts have been made to decrease the initiation and use of tobacco, alcohol and illicit drug. Many of the programs are school based educational programs that aim to increase knowledge and prevent the initiation of substance use. However, despite the implementation of such programs, substance use among adolescence in the United States continues to be a growing concern because of fatal flaws in these programs.

The Drug Abuse Resistance Education (DARE) program is one of many school based tobacco, alcohol and illicit drug education program that targets American youths. Established in 1983 in Englewood, CA the DARE program has grown into the most widely implemented drug and alcohol education programs in the world (4). The DARE program is estimated to reach 26 million children and is implemented in 80% of US school districts and reaches 54 countries. According to their website, the mission of the program is too “provide children with the information and skills they need to live drug-and-violence free lives (4).” The program focuses on preventing the initiation of smoking, drinking and other illicit drug use among youths by helping them resist peer pressure and negative influences while strengthening their self esteem and supporting the positive relationships in their lives. Traditionally and historically, the program consists of a series of classroom lectures targeted for 5^th and 6^th graders and is led by a trained police officer. DARE officers serve as a positive role model for students in the classroom and community. As part of their training, each officer has to complete 80 hours of specialized training in areas of teaching, drug education and child development with the ultimate goal of providing effective drug education and skills to resist peer pressure to the nation’s youth (4).

While the DARE program is typically regarded as a positive experience and is incredibly popular in the United States, historically it has shown minimal effects in curbing substance use among American youth. There are multiple reports in the literature evaluating the effectiveness of the DARE program. Studies have shown it has had significant positive effects in preventing the initiation of tobacco use (5). Children exposed to the DARE program were 5x less likely to initiate smoking than their controls (5). However, studies have shown conflicting results regarding the effects of the DARE program on other health behaviors. The conclusions of these studies has shown that the DARE program had minimal, yet positive, effects on preventing drug and alcohol use among adolescence (6,7). Because of this, over the past few years there has been drastic remodeling of the program. It has implemented many changes and modifications in hopes to achieve more significant results. The program, though still taught by trained police officers, now allows for some flexibility in the lesson plans in hopes to address issues that may be relevant within a given school district. New lesson plans include topics like gangs, cyber bullying and methamphetamine use. DARE instructors focus on facilitating small peer learning groups in addition to conducting the traditional lecture style of the original program (4). Under the new program, high school, elementary and after school programs have also been created to help increase the programs effects. However, the overall goal and mission of the program has remained the same. The DARE program continues to educate children and adolescence on substance use and abuse, correct common misconceptions surrounding the prevalence of drug use, in addition to improving skills to resist peer pressure.

Despite the remodeling of the DARE program, it still continues to produce less than ideal changes in alcohol and drug initiation. Though rates of cigarette smoking continue to decline over the years, daily marijuana use has increased from 2009 to 2010 and now surpasses cigarette smoking among America youths. In 2006, 53.9% of American youths (12-20 years) reported using alcohol in their lifetime and 46.1% reported using it within the past year (1). The DARE program continues to be ineffective in changing substance uses behaviors because there are fundamental flaws in the program which need to be addressed and changed in order for the program to be effective. First, the DARE program is based on the Health Belief Model and acts on an individual level. The program underestimates the social influences that impact and influence American youths when making the decision to use tobacco, alcohol or illicit drug. Second, the program’s authoritative and demanding messages can bring on feelings of psychological reactance among students which hinders the success of the program. Lastly, the messages conveyed to students about individuals who use tobacco, alcohol or illicit drug are very negative and portray them as criminals and bad people. This can alienate or decrease self esteem in those who are currently using, know individuals in authority or higher social influence who are using or those at the greatest risk for initiation of drug, alcohol and tobacco use and thus fail to reach American youth in its entirety.

Critique 1: Knowledge is Power, but not Control

In its current format, the majority of DARE lessons focus on educating the students on the negative health effects of tobacco, alcohol and illicit drug use. The structure of the DARE program is primarily modeled after the Health Belief Model and the success of the program is based on the assumption that adolescence engage in substance use because they are unaware of the negative health effects. According to the Health Belief Model, it assumes that when making a health decision or behavior change, an individual will consider the threat of the given health problem, the costs of not taking action and the benefits of taking action. If the benefits of taking action outweigh the costs of not acting, individuals will engage in that behavior change or make that health decision (8). The DARE program, according to this theory, assumes that adolescence and children engage in substance use because they are not properly educated on the harmful effects of tobacco, alcohol and illicit drug use. Therefore, if you properly educate them on the health risks and the negative impact drugs will have on their lives, they will make logical and rational choices and engage in healthy behaviors and avoid tobacco, alcohol and illicit drug use. The DARE program works to promote positive health behavior and choices at on individual level through this type of education.

While there is validity in the Health Belief model and has been effective in influencing health behavior changes, it is inappropriate in the setting of child and adolescent drug education and prevention. This model, and therefore the DARE program, excludes emotions and the social context that surround children and adolescence. These social factors have a significant impact on the decision making processes in adolescence and the DARE program fails to appropriately and efficiently address these influences. The program does make attempts to address these social influences by teaching the students various skills and methods for resisting peer pressure. However, these skills teach children to act against existing social influences, which make these skills not practical or translatable to real life situations. These skills are only useful if there are motivating factors and social support for their decisions to resist peer pressure and not partake in tobacco, alcohol and illicit drug use (13). The DARE program, though it has made attempts, does not adequately educate students on the appropriate information or skills necessary to support their peers when choosing to not partake in tobacco, alcohol and illicit drug use. The DARE programs inability to account for these social influences is a contributing factor to the lack of success of the program.

Critique 2: Just Say No to DARE

The DARE program has a variety of slogans they use to convey their messages but probably the most recognized slogan is, “Just say no to drugs.” While there are good intentions behind these messages, these slogans may actually be contributing to the lack of success of the DARE program. Declarative statements delivered by authority figures can elicit feelings of social reactance among the students. Originating in 1966, Brehm first described the Theory of Social Reactance. According to this theory, every individual has the freedom to make health decision when and how they like to. However, if this freedom is take away or threated, the response individuals experience is psychological reactance (10). When individuals experience psychological reactance, they will take actions to recapture that freedom or prevent it from being taken away. Thus, they will act in the opposite direction of what was intended. In the context of the DARE program, their messages, such as, “Just say no” can seem threating to a child or adolescences. Therefore, contrary to the goals of the program, adolescence take measures to secure or take back control of their freedom. This can lead to the initiation and use of tobacco, alcohol or alcohol. In the DARE program, these messages are being delivered to the students by the highest and sometimes feared individuals, police officers. Though they are there to promote good relationships, utilizing a police officer to be the messenger of such slogans can push students farther to the other end of the spectrum than what was intended (11). By eliciting psychological reactance with their slogans, the DARE program further hinders the success of the program.

Critique 3: It’s The Message and the Messenger

The primary goal of the DARE program is to decrease the initiation and use of tobacco, alcohol and illicit drugs among the entire adolescent population in the United States. Though recently a few changes have been made to reflect cultural differences among the nation’s youth, the structure of the program is still based on providing drug education and prevention skills through a series of 10 standardized lesson plans (4). These lessons portray individuals who use drugs as strangers, bad people, and criminals. These images are reinforced by students and police officers. The program utilizes a “one size fits all” theory to educate adolescence on drug use and abuse. However, this universal curriculum delivered by police officers alienates the part of the population that is at the highest risk for drug use and fails to address cultural differences among the nation’s youth.

There are cultural, social and community differences among youths that influence the perceived relevance of the messages taught through the program. The model used to crate the DARE program, the health belief model as described earlier, also fails to recognize cultural and social differences that influence adolescent decision making and perception of drug and violence. Ignoring these influences can make some lessons seem irrelevant or not realistic in a particular environment. The program does not have the capability to address some of the significant risk factors that exist within a given district. Therefore, because of this design, the DARE program fails to address all the factors that contribute to drug use and is thus ineffective in preventing substance initiation.

In the Unites States, adolescence with conduct problems, poor peer and family relations, and environments where drugs or alcohol are used regularly are at the highest risk for the initiation of drug and alcohol use (2). Similarly, lack of inhibition and risk taking predict earlier and more frequent use of substances. Thirty seven-51% of adolescence (13-17) who have committed a crime have also used drug, versus the 1-5% of non-criminals. Adolescence who are in this high risk group tend to already have negative views of police officers (11). A police officer is not an effective messenger about the risks of drug use and thus the message fails to affect the behaviors of children at high risk and alienates them from the authority and their peers. Although police are regarded as a positive feature to the program, adolescence in the high risk group becomes further alienated from their peers .

Similarly, the program criminalizes the use of tobacco, alcohol and drug use which can deliver conflicting messages to adolescence that are currently engaging in such behaviors or adolescence who know authority figures who are participating in tobacco, alcohol and illicit drug use. The DARE program promotes an image of drug uses as negative and bad people. Children who are at risk for these behaviors can reflect that negative association on to themselves and push them closer towards drug use.

The Critique

By utilizing public health models and theories, such as the social learning theory, social norms theory and reframing theory, it is possible to effectively correct the flaws that prevent the DARE program from being a successful substance initiation and prevention program. The new public health initiative would be a combined effort between the local police departments and school districts to create a two part afterschool drug education and prevention program for 7^th and 8^th grade adolescence. The program would allow students, with guidance from their teachers, to create “teams” that consist of the peers in their social network. Each “team” would have a high school “mentor” who is assigned to accompany them throughout the course of the program. The actual program would consist of two distinct parts; a drug education program delivered by a trained police officer and a confidential interactive discussion and action session mediated by the high school students. There would be a “core curriculum” of topics and education sessions, yet there would be the opportunity for the students themselves to suggest topics which they’d like to learn about. Each day of the program, the teams would elect a leader to choose which topic they would like to learn about on that particular day. The message and objective of the program would be to provide adolescence accurate information about tobacco, alcohol and illicit drug use as well as provide them with skills and practical experience to make healthy life choices, live drug free lives and recognize when their peers may need help. By changing the structure, delivery and messages of the DARE program, this new program hopes to decrease drug use among the nations youth and be successful in the areas where the DARE program failed.

Correction #1- Change the Messages

As stated earlier, psychological reactance is the feeling that one has when there is a perceived threat to their freedom of making their own health decisions (10). The DARE program is full of statements, messages and themes which elicit psychological reactance in adolescence. Therefore, in order to be more successful, this new program would have to remove these statements and replace them with messages that promote feelings of ownership over their decisions and pride in their choices. It would stress the benefits of living a drug free life rather than the consequences of using drugs.

Though the ultimate goals of the new program would be similar to those of the DARE program, (helping kids make healthy decision and be drug free), by utilizing the reframing theory, they can be turned into messages of support and encouragement. This would take away the perceived loss of freedom that the DARE program promotes. Replacing these negative and authoritative statements with ones of encouragement and support such as, “Say Yes to Being Drug Free” are less likely to elicit feelings of psychological reactance because they no longer threaten their freedom of making health choices. Similarly, by giving the students the choices within the program promotes a sense of control and ownership of their decisions (12). If, in conjunction with the framing theory, the program is marketed to youths as a movement they choose to be a part of, this too can promote feelings of ownership over their decisions and reduce feelings of psychological reactance. Evoking positive feelings and associations that relates to their core values further decrease the perceived loss of freedom associated with the DARE program. Through these measures, which are influenced by public health theories, this new program has the ability to be more successful in preventing substance use simply by reframing their slogans.

Correction #2- Utilize Peers and Peer Relationships for the Best

When youths transition from early adolescence to middle adolescence, the level of importance given to their parents influence on their health decisions shifts to that of their peers (3). This shift in influence, if marketed and utilized in the correct way, can have tremendous positive impact on the prevention of drug initiation and use. By utilizing theories such as the social learning and social norms theory, this new program takes advantage of the influence peers have on each other while correcting and changing the norms within that peer group about drug use and abuse (13).

The social learning theory, proposed by Albert Bandura, recognizes and utilizes the influence peers have on each other to promote behavior change. The theory focuses on the fact that learning and behaviors exist within a social context (15). The theory explains behaviors by saying that people learn behaviors by observing and modeling their actions after their peers. According to this theory, an individual's environment affects their behaviors and in turn, their behaviors create or change their environment (15). When utilizing this theory to promote behavior change, it is incredibly influential in a social setting and when peer influences are involved. Therefore, in the new intervention, because peers have such a huge impact on each others behaviors during this time frame, utilizing the social learning theory is the most effective and appropriate way to induce behavior change.

In the media, images, preconceptions and beliefs about drug and alcohol use bombard the nation’s youth. They are continually exposed to influential or popular celebrities glamorizing drug use. Adolescence end up develop misconceptions and false believes about drug use. A successful prevention program would have to correct beliefs about substance use to reestablish conservative norms and create positive role models which support and endorse these norms (13). The new program aims to fulfill these goals by utilizing the ideas and framework of the social learning theory.

To do this, the program begins by allowing the students to self select their peer teams. By doing this, the program is creating a smaller, more homogeneous population that has similar values and influences over each other. These teams should ideally represent the different social and peer groups that exist within the schools. Each team would then have a high school student mentor that possesses natural leadership skills and popularity. Each mentor would share similarities with their peer team such as gender, values and interests. Having similar interests and values allows the mentors to be considered a part of their social group yet also have a positive influence over them. In the context of the social learning theory, these mentors are intended to be positive role models for their team and someone whom they can model their behaviors after. It has been found in previous studies that positive peer leaders are more influential when leading a prevention program than those that are ran by adults (14). Utilizing peer led discussion groups for part of the program will provide opportunities for students to participate in activities and model their behaviors after their peers and mentor within these groups. There would be an emphasis on skills and actions which promote a healthy lifestyle, build self esteem and confidence within their own peer group. Through these efforts, students will be able to use peer pressure in a positive way to change and discourage drug use among their peers. With support from the social learning theory, the new program will be able to influence more people in a positive way by using positive role models and will effectively address the lack of social influences the DARE program fails to address.

Correction #3- Provide Socially and Culturally Relevant Information

At this age, adolescences are extremely influenced by their peers and social networks and this influence is recognized by the social learning theory. As mentioned earlier, the social learning theory states that learning and behavior change occurs within a social network at a group level (15). Therefore, by letting students to choose their peer groups, this allows them to place themselves into groups with similar societal norms and ultimately influence each other. Similarly the team should represent part or all of their social network as well as the different groups and values that exist within their community and school district. Expanding the curriculum and allowing teams to choose their own topics will increase the relevancy of the topic within their peer groups. The skills the students learn will be far more relevant, applicable and useful if they are learned in the context of their peer group and community values. They also can account for the cultural, communal differences that exist between school districts. This method also creates opportunity to influence high risk adolescence by creating a social group and providing a mentor which is similar in most ways to the high risk group, except for drug use, and will provide guidance and serve as a positive role model for this vulnerable group. By taking these steps to promote diversity and minimize stigmatization, this program will be more successful than the DARE program.

Lastly, a key component of the program would be to help kids recognize when their friends or family members may need help with a drug or alcohol problem. Being able to recognize these situations in their friends or family members would allow them to act upon these situations within their peer group before such behaviors became the new social norm of the group (13). This would also not criminalize all users and abusers as the DARE program does, but rather turn them into individuals who need their help. The drug users depicted in the DARE program are depicted as strangers, criminals and unrealistic, when in fact the majority of adolescences report getting marijuana from their friends. This component of the program would remove some of the conflicting messages delivered to the children about individuals who use drugs and make them more relevant to the students’ social and communal situations and thus more realistic.

Conclusion

The DARE program is one of many programs aimed at decreasing and preventing substance use among adolescence. The program attempts to achieve these goals by educating adolescence about the truths of substance use and the harmful health effects of tobacco, alcohol and illicit drugs. This program is based largely off of the health belief model and therefore has many flaws because it fails to take into consideration the dynamic process and multiple factors considered when making heath choices as an adolescent. The DARE program fails to consider or address social influences on decision making, creates feelings of psychological reactance and alienates part of their target population. Because of these reasons, the DARE program is not effective in preventing substance initiation or use and a new model must be created. Developed here is a new drug prevention and education program which addresses the failures of the DARE program in hopes of being a more effective tool in the prevention of drug use among adolescences. By utilizing various public heath models, such as social learning, marketing and reframing theories, this new program utilizes the influence peers have on each other to promote positive health behaviors and decisions making amongst the different peer groups. By providing students with choices and creating ownership over their decisions, this helps decrease psychological reactance by not threating their freedom of choice, and promotes their ability to make choices which are relevant to them and their peer groups. This new method provides drug education and prevention skills within the context of their social group, culture and community so the information is relevant, relatable and realistic and no longer alienate specific populations of adolescence. By addressing these flaws and making these changes, this new program has the potential to decrease substance initiation and use among the nations youth and produces results where the DARE program failed to do so.

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