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PSHE and Drug Education - why bother? Does it really have impact?
“The link between educational standards and the well-being of children and young people is well proven and PSHE Education offers a significant route to strengthening this relationship.”
DCSF and Ofsted, (2008): Indicators of a School's Contributions to Well-Being - consultation document, www.Ofsted.gov.uk/ofsted-home/consultations (accessed June 28th 2009)
“PSHE Education is increasingly seen as a key priority for improvement for any effective school and underpins effective learning.”
Healthy Schools, (2008), PSHE education Guidance, pg 51
With quotes like these from such influential national bodies the educationally uninitiated may be excused for assuming that PSHE (Personal, Social, Health, Education) enjoys a high profile and influential existence throughout the English schools' system, when - in my experience - the fact is that in many schools; especially secondary schools, it could not be much further from the truth. These positive and seemingly revolutionary sentiments as outlined by Ofsted and Healthy Schools must surely leave many of us wondering why the subject of PSHE is often misunderstood and overlooked, as demonstrated in the following Ofsted finding.
“Too many schools do not base their PSHE curriculum sufficiently on the pupils' assessed needs. The area recruits few teachers with directly relevant qualifications to teach PSHE. Many schools focus narrowly on assessing pupils' knowledge rather than determining the impact of their PSHE provision on improving pupils' attitudes and skills.” Ofsted (2007) Time for Change pg
The recent Joint Area Review (JAR) report for the local authority in which I work reflects national Ofsted findngs and states that the authority should “Ensure that a high priority is given to personal, social and health education (PSHE) in schools”. (****)
The aforementioned quotes clearly illustrate the discord between identified ‘best practice' and ‘current practice' re-inforcing my own professional experiences in the world of PSHE.
These quotes only nibble into the iceberg of conflict evident throughout the paradox of PSHE. Even the subject's name can cause confusion; Personal, Social, Health Education (PSHE) in Primary schools, sometimes with the addition of Citizenship, and Personal, Social, Health and Economic Education (PSHE Education) in our secondary schools. For the purpose of this review I refer to the subject as PSHE. PSHE includes an array of topics ranging from healthy eating to the recognition of feelings and emotions.
In my role of PSHE Curriculum Consultant with a remit for supporting the National Healthy Schools Programme (NHSP - a Government funded Education and Health Initiative) I read many publications and documents produced by influential national bodies such as the DCSF (Department for Children, Schools and Families), Ofsted (Office for Standards in Education), Healthy Schools and QCDA (Qualifications and Curriculum Development Agency - formally QCA). It is not until I reflect upon the plethora of papers and strategies published by these organisations that the common agendas and alignment between them becomes apparent.
The documents and publications produced by the aforementioned bodies form the basis of my professional role. The majority of what I believe, say, do and promote can be traced back to these seminal publications. However when a senior member of a key drug agency in the Local Authority informed me that they do not invest in Drug Education because although there is evidence to support development in pupils' attitudes and knowledge, there is no evidence to support that there is any positive behavioural change I was spurred on to investigate further.
Throughout this piece of work I will be explicitly examining the role and place of Drug Education both within and outside of PSHE. I intend to take a look at some of the history, developments and philosophies which underpin Drug Education in the hope of discovering whether there is evidence to support the belief that it can indeed have a positive impact upon the attitudes and behaviours of young people . I will consider how best practice; as promoted by Government bodies supports and/or contradicts my findings. I endeavor to critically appraise several of the most notable Drug Education Programmes used in schools across the world, highlighting their main features, study methods and results.
Background to Drug Education
Policies and ideologies surrounding Drug Education have emerged, declined, altered and developed over a number of years. Some of the major milestones around drugs and Drug Education have been;
1988 Introduction of the National Curriculum,
1995 Government strategy Tackling Drugs Together- with the addition of Drug Prevention in Schools Drug Education Curriculum Guidance for Schools 4/95,
1998 Tackling Drugs to Build a Better Britain and the corresponding document Dfee: Protecting young people; Good Practice in Drug Education in Schools and the Youth Service,
2002 Hidden Harm,
2004 Drugs: Guidance for Schools - which schools should be using as their current reference material.
2008 saw the Drugs and Entitlement for all Review *****
The introduction of the National Curriculum in 1988 ensured that Drug Education was on the education agenda - not prioritized through PSHE as it is today, but as part of the Core Science Curriculum.
Drug Education has a chequered history. Its focus and priorities have been subject to change depending upon political agendas - it is not hard to understand that measuring its impact is a complex task.
Through the 1970s until the present day the major approaches taken towards Drug Education in the UK have been:
- Scare tactics - the ‘just say no approach as made popular by the Grange Hill cast
- Information based education which aims to give unbiased actual information about Drugs and Drug Education
- Self empowerment education which aims to boost self esteem, assertiveness and decision making skills, and increased belief in personal interest and control
- Situational education which acknowledges the social context of and influences on personal choices around drug taking
- The cultural approach which favours a broader context of the life skills teaching, acknowledges the influences of the home communities and work and on lifestyle and behaviour
O'Connor. L, O'Connor. D, Best. R (1998) pg 65
Even though many of these approaches are ‘out-dated' and not deemed ‘best-practice' they are often evident in the schools in which I work, either used in isolation, but more often used in combination. Back in the early 1990s Swadi had already indicated that there needed to be a “rethink of prevention strategies with a move away from the didactic instructional methods currently employed and the adoption of a holistic approach towards the issue of health and behaviour in adolescents.” (Swadi. H, (1992)
Approaches to Drug Education
D.A.R.E - America
Possibly one of the most well-known and widely used Drug Education programmes is the American DARE (Drug Abuse Resistance Education). Established in 1983 DARE has branches in many countries including the UK. They state that the programme is implemented in over 75% of America's school districts and in 43 countries around the world (see www.dare.com), although I could find no independent evidence to support this, my findings being shared with Skager. R Pg 578. According to the DARE web-site pupils taking part in their programme are 5 times less likely to start smoking than pupils who had not taken part in their programme. They go on to say that “DARE teachers children how to resist peer pressure and live drug free productive lives”. Highly successful claims, however there are several paradoxical issues which arise from this. Independent evaluations of the original DARE programme found no evidence in alcohol and drug use reduction, with one study showing a higher prevalence among suburban youth. Lynman et al (1999) have also drawn similar findings. Skager continued to presume similar findings in a (pg 578 of R skager) 10-year follow-up of DARE pupils.
Interestingly DARE's position of Drug Prevention goes against the UK Government Drugs: Guidance for Schools 2004 document . DARE's stance on leading ‘Drug free lives' is fundamentally floored in the drug taking society is which we live. Following this argument it could be that the promotion of ill-informed and misconceived Drug Prevention programmes such as DARE undermine other evidence based initiatives and UK Government funded training programmes and curriculums.
Interestingly DARE receives much of its funding through the police authorities and from receives funding from “special authorizations attached to bills passed by the congress.” Pg 578 R Shager. It is evaluated outside of any government control, which makes it increasingly difficult for people such as myself to give it a large amount credence.
Life Skills Training (LST) - America
Life Skills Training is another popular Drug Education Programme developed in America over the last 20 years and delivered through the school system. Although it considers itself to be a prevention programme, it acknowledges the fact that its main purpose is to reduce prevalence. It is based on a multi-component design and incorporates information and knowledge, normative expectations, resistance strategies along with decision making, problem solving and analysing techniques, social skills, and strategies to recognize and cope with anger and frustration. This is very much in-tune with the UK's current ‘best-practice guidance'. Supporting the multi-component design is also the belief that delivery should also take a variety of forms ranging from didactic, to group discussions and demonstrations - all with a strong focus on skills training. The programme is intended to be delivered by the class teacher although several providers have altered the programme model for it to be delivered by external providers or peer educators. This draws a parallel to much of the work in which I am involved.
Several studies have shown that the Life Skills Training method demonstrates success, not just on pupils' knowledge and attitudes, but most importantly upon their drug related behaviours. In 1980 a smoking prevention programme taking the LST approach demonstrated that there was a 75% reduction in the number of new cigarette smokers (vol24 pg 253 ****) compared to the control group. However this was measured on immediate effect, the programme took place in only one school together with a comparable control school. Long term studies have taken place showing positive long-term effects of LST. A 6 year randomized study took place with students from 56 public schools in New York. Schools were randomly assigned to prevention and control conditions. The teachers delivering the programme were trained and there was a structured programme which started in the 7th grade. Results showed that 12th grade pupils that took part reported significantly reduced heavy smoking, along with fewer smoking in the last week, or during the last month. The study demonstrated no effects upon drinking frequency, but significantly fewer prevention pupils reported getting drunk one or more times a month, compared with the control group. Fidelity to the programme was seen to be an important factor.
Positive findings indeed, the approach supports much good practice as stated in the Drugs: Guidance for Schools 2004 and is in-line with Healthy Schools recommendations, unfortunately this is another example of a lack of independent research. Statistics on findings were gathered and analyzed by a team of researches that included Botvin - the mastermind behind the development of the LST approach. So can the findings really show objectivity? LST appears on several lists of ‘scientifically proven' programmes which are validated by American Government bodies. Ganghi et al (pg 579 replacing ineffective…..) concludes that “few reports showed substantial impact, and even fewer studies showed substantial impact at longer follow-ups”.
It's My Choice - Norway
It's My Choice project is a multi-component school based Drug Prevention programme aimed at pupils from the ages of 6 - 15. Its primary objective is to influence students at the primary school level in a positive direction in order to delay the age of cigarette and alcohol debut. It takes an attitude-building approach which supports the notion that early influences can prevent children and young people from using drugs. The theory underpinning the programme is that inner personal strength better enables young people to make positive choices for themselves. LST promotes a spiraling curriculum where content is tailored to meet the needs of pupils. The programme considers that the school's approach to education influences the pupils' attitudes and self -esteem and seeks to build positively on this.
This is reminiscent of the UK Drug: Guidance for Schools 2004 which states that “Drug prevention aims to: …delay the age of onset of first use…Drug Education should …develop pupils' personal and social skills to make informed decisions and keep themselves safe and healthy, including: developing self-awareness and self-esteem….” (pg 18) The UK Guidance for schools also promotes a spiraling approach and encourage Drug Education not to been viewed in isolation but as part of a whole school approach, where skills are transferable and inter-related, used - where applicable in a cross-curricular manner.
Although only measured over the short-term results show that “70 % of students at the intervention schools say that they have never tried alcohol without an adult present, while the figure for the control schools is 40%. 56 % of students at intervention schools say that they have never been bullied, while the corresponding figure for the control schools is 28%. 20 % of students from intervention schools say that they compliment others quite often, while the figure for the control schools was 6%.” Web-site *******. The results point to many positive effects of the programme including increased self-esteem, empathy and a better relationship with the other students. Whilst this is no undisputable long-term evidence for reduced Drug use, these skills are clearly related to numerous protective factors highlighted in Hidden Harm (2003?) and could result in reducing risks to many children and young people.
Blue Print Programme
The Blue Print Programme was the largest and most recent multi-component, research-based Drug Education Study in England. Funded by the Home Office, The Department of Health and the Department for Education and Skills (now the Department for Children, Schools and Families) its aim was to “design, deliver and evaluate an evidence-based drug prevention programme.” (pg 21 2007 stirling evaluation) Prevention in this case had been defined as “slowing the normal rate of increase in population-based use prevalence rates of tobacco, alcohol, solvents and cannabis during early adolescence, and reducing the harm to self and others arising from the use of these substances.” (Reference a link to it for further info)
Basically the programme aimed to:
“reduce the number of young people using drugs;
delay the onset of drug use;
minimize the harm caused by drugs; and
enable those who had concerns about drug use to seek help.”
At first glance the study methods appear robust, with 30 schools initially taking part (one school later dropped out) 24 schools delivering the Drug Education programme and 6 comparison schools . Criteria for selection were set out and applied in a systematic manor. Selection also took account of the Index for Multiple Deprivation. (A more detailed account of this can be found at pg 23 stirling report).
The components making up the programme were:
15 x 50 minute Drug Education Lessons (10 in Yr 7 and 5 in yr 8),
Schools Drug Adviser support
Parent skills workshops and materials including a parent magazine which was to encourage communication between parents and children
Media coverage and support
A Health element which targeted retailers of alcohol, tobacco and solvents
A community component - which appears to have been far less structured and focused than the other elements. There was no lead contractor for this part of the programme and available information appears quite vague.
A huge array of individuals and agencies were pinning much hope upon the Blue Prints Programme. It had been developed using a wealth of prior information and research, it cost a lot of money (reportedly around £6 million)and took many years to design, implement and evaluate; but it does appear to have had several floors from the outset. Many people (including myself) were expecting that this programme would provide a definitive way forward for Drug Education; but it appears that from the very beginning it could only ever be an exploration of trail conditions; it could not be definitive. (Raab et al. 2002) concluded that a definitive trail should be made up of no fewer than 50 schools. A further nail in the coffin for those of us expecting a definitive trial, came from the Medical Research Council (MRC) guidance on the development of evaluations of complex interventions. This advises a “cumulative approach to understanding how outcomes are achieved, moving from theory, to modeling, to an exploratory trial to a definitive trial” (MRC 2000). This was highlighted by the stirling report in 2007, but was apparently ‘missed' in the original development of the programme.
Has the Blue Prints Programme progressed our understanding of effective Drug Education? If we are to share the opinions and feelings of several journalists such as Mark Easton (17th September 2009) we would surely feel most despondent facing the fact that even Home Office scientists could ‘bungle' research. This is an simplistic message to take from the findings, it certainly makes for good headlines and keeps the cynics of this world happy; but it is not helpful in advancing our understanding of effective Drug Education. Ben Goldacre in his ‘Bad Science' column in the Guardian 19/09/09 reinforces Easton's stance and makes several convincing points about similar issues stating that “There were also offers of advice from experts in trial design, such as Prof Sheila Bird of Cambridge University, who offered to help them do a meaningful trial on the available budget.” She wrote in an e-mail to the BBC "I/we thought the decision-making so obvious = NOT to go ahead that we did not assiduously follow-up to ensure that the OBVIOUS decision was actually made!" Clearly insinuating that the project was known to be floored *** from the start and that it should have been altered or canned. If these opinions and statements are correct I find it hard to understand why the Blueprints Programme continued the way it did. I can only trust in my own possibly naive instincts and believe that the Blueprints Programme began with the best of intentions.
Whatever the facts, the Blueprints Programme has given people in the world of Drug Education assistance with: the structuring of Drug Education sessions, issues around working with parents and the importance placed upon fidelity to the programme. The programme has raised the profile of Drug Education highlighting the importance for more research and it very clearly emphasise the mistakes from which we must learn.
I still grapple with the reasons for the apparent ‘failure' of the Blueprints Programme to deliver. To help me further understand the possibilities behind this I considered Lawrence W. Sherman journal on ‘Drug - free schools'. In this he suggests that government bodies and representatives invest money in projects which are of concern to the general public (the health and well-being of children and possible related drug use/misuse issues being a fine example of this) but with no regard for any proven impact of the programme itself. By doing this a government is able to demonstrate its compassion for the public, no-one is able to accuse politicians of being in-different to problems in society and other political parties also have their hands tied to support the project as if they are seen to disagree with the initiative they are considered uncaring and un-supportive by the general public.
An interesting position which would explain the Blueprints failure to deliver. Sherman also makes several other interesting observations. He points out that there is very little drug use in schools, alluding to the fact that most drug use takes place outside school premises and in the local community - which is true - but he fails to make the link that if an initiative is proven to be ‘effective' it is likely to have positive impact upon the pupils and their community. This point is illustrated by Bruno V. Manno in his comments on Sherman's journal. Where he also supports the view that “schools can contribute to modifying the effects of outside influences and overcome family background factors and community liabilities.” etc pg 162
So after all this - should we bother with Drug Education in our schools? And does it have any impact? I believe that the answers to these questions comes in 3 parts.
We want to see quantitative, longitudinal data supporting all of our efforts in the world of drugs and Drug Education and on this front, for me, the evidence is not yet strong enough. Researchers must learn from the huge amount of world wide studies and work that has already taken place.
There are many issues which need addressing; even after all my research my initial suggestions are quite basic. The first we need to be clear about is; What constitutes Drug Education? Before any further research can provide meaningful results we must decide whether Drug Education is a programme containing a series of structured lessons which focus upon facts, skills and attitudes around drugs, where fidelity plays an important role, or whether it is bigger than this? There is evidence to suggest that the size of a school, its management system, behaviour management procedures, teacher pupil relationships, teacher parent relationships, support for the development of pupil self-esteem and general school environment (as highlighted in the Norwegian It's My Choice programme) impacts upon whether or not young people choose to take drugs. Research and the findings should have a clear degree of independence as without this any programme is open to doubt. We must be clear about what we mean when we say the word Drugs. Are Drugs the demonic substances which spring to the front of many people's minds when the word is uttered, or are they substance which when taken “changes the way a person feels, thinks or behaves.” ******** Do we include tea, coffee, and paracetamols when looking at Drug Education? Do we consider Drugs which people may need to be healthy? Thought needs to be given to whether our personal experiences enable us to be able to deliver Drug Education in an effective, value free manner? We also need to explore whether Drug Education with a preventative slant can ever be value free? In fact, should it be completely value free if we want future generations to make ‘healthy decisions', as this clearly comes with its own agenda.
Many of these realizations have been recently highlighted in the 2008 Drug Review: An Entitlement for All where it makes several
recommendations to the Government, one being to “Promote a wider understanding of the aims of drug and alcohol education among young people, parents, carers, the children's workforce and the wider media.” (*****), another is clarify the aim of Drug Education. As it stands Drug Education and Drug Prevention are defined separately. If we are to apply the current definition of Drug Education as suggested in Government Guidance it would clearly have no impact upon pupil behaviour. It would only be when we looked into Drug Prevention where any relation to behaviour could be made. The Government have accepted all the recommendations made in the review and there is to be further Govermnet Guidance disseminated as a result.
The UK takes a generally positive and pro-active approach to Drug Education, this has been re-affirmed by my research and by considering approaches taken by other countries. Drugs: Guidance for Schools is a comprehensive document and is re-inforced by all of our Government, Educationally influential bodies and the Police - current Government responses indicate that further guidance will strengthen existing documentation. Since 1988 Drug Education has generally developed, it has not radically changed. I think this can be demonstrated in the universal decline in the prevalence data for children and young people (appendix **)
High expectations are placed upon the shoulders of Drug Education, we must question ourselves as to whether we are asking too much from one subject? ********
‘Expectations of the impact of effective drug and alcohol education in our schools are high, far higher than they are for most subjects. The expectations of drug and alcohol education are that it will increase pupils' knowledge, change their attitudes and enhance their skills as well as having an impact on their behaviour'. (Ofsted 2005)