Winter 2019

Building on Strengths and Working Together: Comprehensive Approaches to Preventing Problematic Substance among Youth

Now is a critical time for Canadians to reflect on how we can collectively address problematic substance use among youth across the country[1]. This is one the reasons my report on the the state of public health in Canada last year focused on this issue: https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/2018-preventing-problematic-substance-use-youth.html.

With the growing epidemic of opioids deaths across the country, the recent legalization of non-medical cannabis, and the wide range of health and social harms of alcohol, there is a growing need to examine and identify the role of schools in promoting positive mental health[2] and preventing problematic substance use among youth.

There is no single cause of problematic substance use (Figure 1)i. Schools are uniquely positioned to contribute to prevention efforts by addressing multiple and interacting protective and risk factors. School-based programs are unparalleled in terms of their ability to reach large numbers of youth at a critical period in their lives when lifelong behaviours often become established. The earlier one starts using substances, the more heavy or frequent the use, the higher the risk of problematic substance use i. Factors such as academic performance, engagement in school life, and a connection to school where students feel accepted, respected, included, and supported by others protect against problematic substance use i. In addition, certain types of school-based programs have been shown to facilitate positive mental health by going beyond addressing risks to building resilience i

Figure 1: Risk and protective factors associated with problematic substance use in youth i

Research shows that school-based substance use prevention programs that take an abstinence approach are ineffective and can potentially be counterproductivev. For example, several studies have shown that Drug Abuse Resistance Education (DARE) programs may actually increase substance use among students by alienating them, which can undermine the important protective influence of school connectedness v. On the other hand, school-based programs have been proven to be effective when they employ comprehensive, strengths-based approaches that enhance resilience and protective factors among youth and are rooted in local context i. Some of the characteristics that make these programs effective are described below.

How to build effective school-based substance use prevention programsi

  1. Adopt a strengths-based perspective to building skills and resilience among youth and their families

Purely knowledge-based programs do not lead to significant changes in youth behaviour. Programs that teach youth to resist risky behaviours and enhance resilience show more promise when combined with elements that aim to build resilience through life skills training (i.e. communication and social skills) and cognitive competencies (i.e. goal orientation, stress management). Combining these programs with parent- and family-oriented programs can lead to even greater benefits for youth by building caregiver skills and resilience.

2. Integrate principles of self-determination and cultural safety

For Indigenous youth, school-based programs have to acknowledge the impact historical and intergenerational trauma, including colonization, loss of traditional culture and language, and experiences with residential schools, have had on First Nations, Inuit, and Métis families and communities across the country. This involves acknowledging that school-based programs for Indigenous youth need to be founded on holistic approaches to healing and wellness that are based on the strengths and resilience of First Nations, Inuit, and Métis peoples (i.e. cultural values and teachings that place importance on Indigenous languages, traditions and culturally specific knowledge on resiliency, risk, and protective factors).

3. Address the key role of social norms

A key element of successful prevention programs is that they address social norms. Perceptions of what is deemed “normal use” can influence youth use of substances, as well as the availability, marketing, and the price of substances. For example, because of its social acceptance, risky drinking is high among Canadian youth v,[3]. Cannabis use is already relatively common among Canadian youth, and nicotine vaping among teens is increasing v,vi.

In light of recent legalisation of non-medical cannabis, we want to make sure that cannabis does not become the new alcohol and that young people can make informed decisions about use. The Lower-risk Cannabis Use Guidelines iii can offer such guidance by informing educators and youth of the harmful consequences of use and by promoting safer use. However, we know that interventions that only target knowledge and awareness of the dangers of substance use do not change youth behaviour.  There is promising evidence that shows that school-based programs that combine social competence and social influence can prevent cannabis use among youth iv.

4. Ensure that programs are age and developmentally appropriate

Prevention interventions are most effective when delivered prior to when substance use begins or at the very early stages. As such, prevention programming can be implemented at all grade levels, particularly at ages that represent key transition points when youth generally begin to use substances. This means that school-based programs may be most effective if implemented during the middle-school years when experimentation with substance use is most likely to occur

5. Foster inclusion and eliminate stigma and discrimination

There is ample evidence showing that youth who experience stigma or discrimination are at heightened risk for problematic substance use. This includes youth who experience stigma and/or discrimination based on their race/ethnicity, Indigenous identity, mental health status, disability, and/or LGBTQ2 status.

Schools can help to eliminate stigma and discrimination by adopting equitable and compassionate policies, practices, and language. This includes making sure that educators can help to create and foster a safe, supportive, and non-judgemental environments where students can feel comfortable having discussions about substance use. It also means creating inclusive and supportive spaces that embrace diversity by adopting policies that discourage discrimination and bullying and by investing in safe spaces (i.e. alliances for LGBTQ2 youth or youth of colour).

6. Be interactive and youth-led

A wide body of research suggests that to be effective, programs need to consult youth to inform, design, implementation and evaluation. Interactions between teachers and students (and among peers) that stress communication and balanced discussions about substance use can improve prevention programs. Student feedback can be routinely sought and used to inform ongoing and future interventions.

(See the 2018 CPHO report for detailed examples)

Summary

Why some young people use substances and some of them experience problems is complex. Many underlying and interconnected factors drive harmful use like physical and sexual abuse, family conflict, lack of stable housing and stigma and discrimination. On the other hand, protective factors such as school connections, positive relationships with friends and family and community safety can increase a youth’s ability to cope with adversity and prevent him or her to use substances in a harmful manner.

In November 2018, at a school stakeholder forum, I had the opportunity to hear youth, educators, community-based youth organizations, mental health professionals, and research experts identify enhanced ways we can work together to support students in school settings to face the challenges associated with substance use. I look forward to continued collaboration across sectors to enhance school and community environments to support youth to feel included and connected, buffering against the risk of problematic substance use.

1 Problematic substance use refers to the use of a psychoactive substance in a manner, situation, amount, or frequency that can cause harm to the person using the substance or those around them.
2 Positive mental health is the capacity of each and all of us to feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges we face.
3 This refers to consuming 5 or more drinks on a single occasion.

AUTHOR BIO:
Dr. Theresa Tam is Canada’s Chief Public Health Officer. She is a physician with expertise in immunization, infectious disease, emergency preparedness and global health security. Last year she released a report on preventing problematic substance use among youth
References
i Public Health Agency of Canada. The Chief Public Health Officer’s Report on the State of Public Health in Canada 2018 – Preventing Problematic Substance Use in Youth. 2018; Available from https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/2018-preventing-problematic-substance-use-youth.html
ii Singh, R.D., Jimerson, S.R., Renshaw, T. et al., A Summary and Synthesis of Contemporary Empirical Evidence Regarding the Effects of the Drug Abuse Resistance Education Program (D.A.R.E.). Contemporary School Psychology, 2011. 15(1): p. 93-102.
iii Fischer, B., et al., Lower-Risk Cannabis Use Guidelines: A Comprehensive Update of Evidence and Recommendations. Am J Public Health, 2017. 107(8): p. e1-e12. iv Hammond D., G.S., Policy Approaches for Problematic Substance Use: Evidence Review (Unpublished). 2018.
v Singh, R.D., Jimerson, S.R., Renshaw, T. et al., A Summary and Synthesis of Contemporary Empirical Evidence Regarding the Effects of the Drug Abuse Resistance Education Program (D.A.R.E.). Contemporary School Psychology, 2011. 15(1):p. 93
vi The 2016-17 Canadian Student Tobacco, Alcohol and Drugs Survey. Available online at https://www.canada.ca/en/health-canada/services/canadian-student-tobacco-alcohol-drugs-survey/2016-2017-supplementary-tables.html