A Review of a Traditional Approach to Teen Substance Use Prevention - Gail N. King
PART I: Inherent Flaws in the Design and Implementation of the DARE Program
There are serious public health implications for adolescent substance use. With substance use increasing the risk of traffic accidents (1), risky sexual behaviors (2), developmental problems (1), and delinquent behaviors (3), it is crucial to understand the extent of current adolescent substance use and design implementation strategies which effectively curtail such behaviors. In recent years, adolescent substance use has been on the decline. However, research currently suggests that the rate of the decline has slowed down, or possibly, has leveled off (4). Recent data indicated that 10% of 12 to 17-year-olds reported using an illicit drug in the past month, 10.4 million drinkers are between the ages of 12 and 20, and 16.4% of 16-17-year olds use illicit drugs, which is the second highest rate in the country (5). In order to address the issue of adolescent substance use, national policy has been instituted to pour funding into school-based initiatives designed to prevent substance use within the adolescent population. One of the most well-known school-based drug prevention programs is Drug Abuse Resistance Education (DARE). With programs in over 50% of schools, representing over 80% of school districts nationwide, DARE is the most widely used intervention strategy within schools in the United States (6). With such wide-spread usage, it is important to understand the context for and the effectiveness of this program, and to determine the flaws and room for improvement within its design.
Developed in Los Angeles in 1983, in the wake of the nation’s declaration of war on drugs resulting from concerning reports of significant increases in usage trends during the 70s and 80s, the police-led teen drug prevention program DARE was designed (7). This program aimed to target youth prior to their engagement in drug use, as many believed it was too late to intervene with older cohorts, who were already using. Earlier generations of anti-drug campaigns targeting youth had used strategies that only provided information or utilized scare tactics as their means of curtailing drug use (7). With these earlier methods proven ineffective, the entrance of DARE onto the drug use prevention scene provided a program that vastly improved upon these failed models. In addition to giving youth information on drugs and teaching drug resistance skills, the DARE program taught decision-making skills and used police as teachers, which was geared towards building relationships with youth, which could enhance their social supports. In spite of these improvements, research has shown that the DARE program only minimally decreases drug use in youth, while some research suggests there may be no effect, or even a negative one (8—10). In response to the research, program designers have sought to improve the program model to cover more age groups, and include family outreach and life skills. Although these expansions could result in slightly better outcomes, due to several key flaws remaining at the core of the program’s design, this may not be likely. These shortcomings include the program’s usage of components of out-dated behavior models, strategies that ignore and do not take advantage of the social norms within youth culture, and a message that does not fully take into account the developmental context and needs of youth, but instead, carries the potential for creating and reinforcing problematic labeling of some youth into the category of “users,” to whom the message of DARE is not addressed.
Assumption of Individual Level Rational Decision Making
The first flaw in the design of the DARE program to be considered here is the core assumption rooted in out-dated models of health belief theories. Specifically, at the heart of the program is the assumption that health behaviors occur after a period of rational decision-making at the individual level. Youth are taught a particular decision-making strategy designed for program participants based on each of the letters in the program’s name: D—Define the problem / challenge; A—Assess available choices; R—Respond by making a choice; E—Evaluate the decision. Such an individual-level model of rational decision-making is similar to traditional theories of health belief such as the Health Belief Model and Theory of Reasoned Action (12—15). The Health Belief Model posits that health behavior is the result of a rational process similar to a cost-benefit analysis (12—13), whereas the Theory of Reasoned Action suggests that behaviors are the result of a consideration of outcome expectations and the role of/pressure to conform to social norms (14—15).
Aspects of the Social Learning Theory are also present in DARE’s design. The program utilizes modeling and attempts to enhance social supports through relationships with police officers. Although this latter model is more comprehensive than the first two, it suffers from the same core flaw—the assumption of rational individual-level decision making—which is at the foundation of the DARE model of intervention. Behavior models relying heavily on assumptions that decisions are made primarily based on an individual-level process of rational decision making have been proven ineffective (16—17). Research has shown that these factors are not the sole or primary bases leading to the behaviors of individuals, and that many other factors must be considered with regard to the decision-making process (18). Some crucial factors to be considered are at the macro-level, such as the socio-political and historical context of groups and how that influences individual and group behaviors (19). For instance, for African-American youth, how does a history of injustices at the hands of law enforcement impact the receptivity of youth to uniformed police officers delivering course content? Perhaps pairing officers with prominent and respected community members within the classroom or having police interact with youth in youth centers would be necessary to increase receptivity given the particular historical and socio-political experiences and context of African-American youth. Other factors necessary to consider are at the micro-level, such as the developmental context of individuals and groups. It is this latter piece which will inform the discussion of the next flaw to be considered relating to the design of the DARE program.
Understanding Developmental Context:
While training for police officers delivering the DARE curriculum includes adolescent development (20), the use of such theories to inform program design and delivery may be lacking or insufficient. The program focuses on teaching youth about drugs, decision-making skills, and healthy alternatives to drug-use. The program also seeks to enhance self-esteem, which would likely be rooted in the designers’ understanding of the developmental context of adolescents. Looking at two perspectives on the needs of individuals and developmental tasks of this age group in particular, it would seem clear that there are pre-requisite steps to take before attempting to enhance self-esteem and offering a broader understanding of psycho-social development, of which self-esteem is just one part.
According to Maslow’s Hierarchy of Needs, people have various layers of needs. Designed in the shape of a pyramid, the lower most layers are those needs essential to survival (e.g. physiological needs such as breathing, food, water, etc.) (21). The next layer of needs involves safety and consists of security of body, resources, family, property, morality, and health. Following this is a need for love and belonging, which includes family and friends (21—22). The next layer includes matters of esteem (e.g. self-esteem, confidence, etc.). This is followed by the top-most layer, self-actualization, which includes lack of prejudice, acceptance of facts, and problem solving. Based on this hierarchy, Maslow posits that there is an order to the priority of needs, and that the next highest level of needs does not become a realistic goal until the layer below is fulfilled (21—22). For instance, according to Maslow’s hierarchy, an individual who has unmet needs with regard to food, water and bodily security will be seeking to meet those needs before actively focusing on higher order needs such as friends, self-esteem and creativity. Before a program can expect to introduce concepts of self-esteem and problem-solving, according to Maslow’s Hierarchy of Needs, individuals must first have more basic needs met. Thus, a universally delivered program model may need to be modified based upon the demographics of the people within the setting of implementation.
The other developmental concept that needs to be considered here is Erickson’s theories of adolescent development. According to Erickson’s theories, the major tasks of adolescence are developing identity, defining morality and forging intimate relationships (23). It is during this stage that a life philosophy begins to develop. Because of a lack of experience, these philosophies tend to be rooted in conflict-free ideals rather than a more realistic understanding of life (24). Lack of successful navigation through this stage could result in considerable inconsistencies in and problems with regard to the young person’s sense of self, life philosophy, and ultimately, the life choices that are made. According to Erickson’s theory, since a core task is identity development, this should be taken into consideration prior to seeking to enhance self-esteem. Enhancing self-esteem, in some ways, may require youth to have a more defined and rigid sense of self than is true based on their developmental trajectory. At the very least, this would need to be taken into consideration as the DARE program works with different age cohorts. Older adolescents may have a more defined sense of self and morality, while this may not be the case for younger ones.
Given these developmental tasks, and in particular the goal of identity development, it is crucial to briefly examine a final piece of the DARE model that does not fully take into account the developmental context of youth. This relates to the potential for youth to internalize problematic and damaging labels—which in turn, can influence them in negative and very profound ways as they seek to define themselves in some meaningful way. The program’s message focusing on never starting drug use is embedded in program founders’ early beliefs that they had already lost a generation to drugs, thus needed to target younger cohorts. With this message, it is possible that youth who have tried drugs before may see this program as not for them, as it would seem the program is geared toward “non-users.” Thus those “users,” for whom the program’s message was not specifically designed, run the risk of internalizing this label. According to theories of labeling, this internalizing of an externally derived label can become a self-fulfilling prophecy (25). Individuals can internalize this label, which can then become part of their core understanding of who they are, thus dictating and defining the choices they make (25—26). This labeling-internalizing-self-fulfilling process seems especially geared towards this particular stage in adolescence for which identity development is such a crucial and necessary aspect.
Given this perspective on adolescent development and the dangerous potential for labeling, DARE’s model would need to include curriculum components that address the needs of all youth, regardless of drug usage status, a method used quite effectively in the well-known anti-tobacco intervention known as the “Truth” campaign. In the next section, the “Truth” campaign will serve as a corrective model to inform and address the way in which the DARE program currently seeks to influence adolescent social norms.
Ineffective Use of Social Norms and a Suggested Model for Improvement
Social Expectations Theory suggests that an effective way to impact the choices and behaviors of people is to change norms. Social norms can be considered to be rules or standards of behavior, along with the meaning/significance associated with that behavior, that serve as a guide to behavior (16). Social Expectations theory argues that individual behavior is a direct impact of norms governing the broader society (27). These codes of behavior are usually followed by an entire group, and thus, considered normative behaviors. According to Social Expectations Theory, to change behaviors, one need not focus on individuals or individual-level characteristics, but on the norms that impact and influence all individuals within a group (27).
Examining The DARE program’s design, one sees some evidence of an attempt to impact social norms. With a program in over 50% of schools nationwide, and goals to prevent all kids from ever starting using drugs, the program attempts to foster an environment where abstaining from drug-use is normative. The program also educates youth in order to teach them the actual prevalence of drug use in an attempt to combat the “everybody’s doing it” argument—which is an argument rooted in and reflective of youth beliefs regarding what is normative behavior for their peer group. Of course, DARE focuses on individuals, which is a clear deviation from Social Expectations Theory. DARE seeks to modify social norms by changing individuals one by one, while Social Expectations Theory posits that changing norms will result in individual and group level behavior change in a way that is more comprehensive and long-lasting (27). With the minimal impact of the DARE program’s effects proven to fade over time (7), it would be useful to consider approaches that have a more long-term effect.
While attempts to change norms may be a useful strategy, given certain developmental considerations listed above, a more effective approach for adolescents would likely be similar to the approach utilized in the “Truth” campaign. Specifically, this anti-tobacco campaign targeting youth used marketing strategies to re-frame the idea of smoking into a message that worked within the context of and was compatible with youth norms (28). Instead of falling into the usual strategy of teaching kids of all the harms and risks associated with tobacco use, intervention designers partnered with a marketing agency to research how youth made decisions around tobacco use. What they found was that youth were very well aware of the risks associated with tobacco use, and in many ways, it was this risk that increased the allure (28). With identity development in adolescence often taking on the form of rebellion against societal standards, tobacco use was just one more means to accomplish this end. What researchers designing this campaign discovered, was that youth rejected messages that seemed to be judgmental and preferred not to be “preached at” (28). What was even more informative, was learning that the reasons for tobacco use were not rational, but emotional. For youth, “tobacco was a significant, visible, and readily available way for youth to signal that they were in control” (28). Armed with this knowledge, program designers sought to re-frame the issue of smoking within the context of social norms of youth culture, which emphasized being in control and a desire not to be manipulated. Instead of teaching kids of all the dangers of tobacco use, the campaign focused on informing youth of the efforts of tobacco companies to manipulate youth through deceptive marketing strategies that concealed the true harmful nature of cigarettes in order to get generations “hooked” on tobacco so that the companies could profit financially. Thus, “attacking the duplicity and manipulation of the tobacco industry” became the new rebellion (28).
The campaign’s efforts in Florida from 1998-2000 met with great success. Cigarette use among middle school students dropped from 18.5% to 11.1% (p<.001) and, among high school students, cigarette use dropped from 27.4% to 22.6% (p = .01) (29). The amount of youth who fell into the category of “never-users” increased from 56.4% to 69.3% (p<.001) (29). Given the focus of the DARE program on increasing the number of kids in this latter category, the model used by the “Truth” campaign could be a useful tool in informing future modifications and expansions of the nation’s most widely recognized and implemented, yet not the most effective, drug prevention program.
Public Health efforts to curtail adolescent substance use have taken many forms throughout the years. The most widely used program, examined in this paper, is the Drug Awareness Resistance Education (DARE) Program. Because of assumptions rooted in out-dated health belief theories and an approach that does not fully take into account the developmental context of youth, the program has not been as successful at curtailing drug use as designers hoped it would be. DARE has also only sought to change norms around drug use one-by-one, which is not as effective as trying to change norms and letting those changed norms impact individual and group behavior. An approach that may be even more effective is that which has been used by the “Truth” anti-tobacco campaigns. The “Truth” campaign re-framed the issue of tobacco use and embedded itself within the context of youth norms and attitudes, rather than trying to change them. Although DARE continues to evolve and expand its programming to improve upon its original model, and in spite of the improvements over the earlier models of drug prevention programs, several key flaws lie at the foundation of DARE’s design and implementation, thus reducing efficacy. Addressing these flaws based on the theories and approaches outlined in this essay could result in a program design that has a much more significant and long-lasting impact. While a few alternatives were briefly considered above, a more thorough treatment, which sill address the core deficits of the DARE model previously listed, will be presented in the next section.
PART II: Alternative Approaches to Addressing Adolescent Substance Use
In the previous section, flaws in the design of the DARE model were presented. These included: 1) An approach that relied upon an assumption of individual level decision-making based upon a rational thought process; 2) A need to understand and employ a developmental approach; and 3) An inadequate and inefficient attempt to change youth norms.
Based upon the prior critique of the DARE program, an alternative approach will be presented in this section. This approach will address each of the three major areas previously considered. More specifically, in order to correct the flaws of the DARE program identified in this paper, an alternative approach would need to: 1) Address the problem of substance use prevention from a more ecological framework, not solely relying upon individual-level strategies; 2) Utilize an approach that takes into account the developmental context of youth; and 3) Seek to change individual level behavior by changing social norms—or rather, re-framing the desired health outcome / behavior so that it is framed within the context of youth norms.
The specific proposal for an alternative model will use a youth development framework designed by the Search InstituteSM. This approach will be coupled with a strategy to work within the framework of youth norms. Together, these two foci provide a blueprint for a teen substance use prevention program which is not limited by the particular flaws identified in the DARE program. While these strategies will not be presented as specific changes to the DARE program, they can still be used by program designers of DARE, as well as others, to inform future program modification and development.
Ecological Framework and Developmental Assets
One particular lens through which the problem of adolescent substance may be viewed is provided by the Search InstituteSM, a research institute that focuses on enhancing the health and well-being of youth and children. Through their research efforts, the Search Institute has identified a list of assets, entitled the 40 Developmental AssetsTM (30), which are crucial to enhancing the healthy socio-emotional development of children and youth. This list includes external assets under the categories of support, empowerment, boundaries / expectations and constructive use of time, as well as internal assets, which are categorized under the headings of commitment to learning, positive values, social competencies, and positive identity. A brief review of this list highlights the overlap between these assets and the developmental needs identified by Maslow and Erickson discussed in the previous section. For instance, the Search Institute’s list of developmental assets for youth includes family support and healthy relationships (30). The latter asset is identified by Erickson as one of the key developmental tasks of adolescence (23—24), while the latter is one factor that would contribute to a child’s feelings of security, identified on Maslow’s Hierarchy of Needs (21—22).
The basic premise behind this list is that an increased amount of assets in youth is conducive to and a marker of healthy socio-emotional development, and consequently, healthy decision-making. More specifically, studies have shown that an increased number of assets is inversely related to risky behaviors in adolescents, such as drug use (31—32). This inverse relationship is depicted in Figure 1 (Note: ATOD refers to Alcohol, Tobacco, and Other Drug use):
What this graph suggests is that rather than trying to rationally talk youth out of substance use, a more effective approach might be to learn the number of Developmental AssetsTM youth have, and determine where the deficits are in order to address them.
One benefit of this approach is that it allows the problem of substance use to be addressed at both the individual as well as the community level. More specifically, individual level change can occur by using the list of assets to identify and augment asset deficits in particular youth or groups of youth. At the community-level, this list of assets can serve as the basis to conduct a community-wide needs assessment to determine the capacity of the community to support the healthy development of youth. Identified areas of deficits can serve to inform future program design as well as policy / advocacy efforts. For example, if a community is particularly lacking in the asset category relating to providing youth with constructive uses if time, then community mobilization efforts can be directed towards 1) Developing and implementing more youth programming; 2) Forming relationships with nearby communities that may have more of these opportunities; and/or 3) Advocating for policies and funding to support youth programming in that community. An example of this latter effort has been demonstrated in Boston on a number of occasions. In the early part of 2001, and several years later in 2005, advocacy efforts by youth and youth servicing professionals were crucial in restoring funding to several key community programs in the face of massive budget cuts. Not only do such advocacy opportunities benefit programs, but they also benefit youth, as these opportunities become a positive factor contributing to healthy socio-emotional development and identity formation.
Root Issues and a Social Norms Approach
In addition to understanding and working within the framework of adolescent development, an effective approach to impacting youth behavior would also incorporate strategies to address the role of social norms. One of the most effective strategies which did this was through the drug prevention intervention efforts employed by the “Truth” campaign. A number of approaches used in this campaign would serve as a useful foundation for future drug use prevention programs and strategies. A key piece to the success of this campaign included seeking out youth perspectives to guide and inform the intervention development process (28). This gave program designers a chance to learn about youth norms in relation to how youth felt about smoking and anti-smoking messages. Through these interviews, the role of youth norms regarding tobacco smoke was elucidated and an effective strategy to curtail this was implemented (28).
The “Truth” campaign demonstrated that smoking, a behavior that may have been considered normative, was incompatible with a more important and fundamental need to be in control and free from manipulation (28). This re-framing had the effect of changing youth norms around behaviors that were proven to be contradictory to normative philosophies. In addition to that successful re-framing effort, the campaign further reinforced their message by demonstrating that youth could still fulfill rebellious ambitions by not smoking. The new focus of their rebellion would be the big tobacco corporations attempting to deceive and manipulate youth in order to make a profit (28).
The strategy employed by the “Truth” campaign could be used to inform drug use prevention program development. Program planners would need to begin by involving youth right from the start of the design phase. Program designers would need to talk to youth to learn what young people already know about the risks of drug use as well as the reasons for substance use. The goal would be to learn what youth norms are at play with regard to decisions for and against drug use. This information may be similar to that which the “Truth” campaign learned, but there may be deeper issues at work as well, such as self-medication or desires to escape and avoid pain. Program designers may want to speak with mental health workers and sociologists as well to learn more about underlying reasons for drug use.
Armed with this knowledge, program designers would need to frame the issue of drug use prevention within the context of youth norms—which can be done with regard to philosophy, behavior, language/means of communication, etc. One example of using a norm related to a philosophical framework would be to take advantage of the need for individuality expressed in the commonly heard expression, “I’m just gonna do me.” This phrase expresses a sentiment of each person doing and being about that which is unique to his or her own individual personality. A way to frame drug use as counter to that is to emphasize the way in which drugs take over and can lead to a person experiencing a loss of self in the process. Another frame, which uses a different youth norm, relates to channels of communication, and is employed by a teen led anti-drug program in Medford, MA. The regional Youth Advisory Council, now re-named TADD (Teens Against Drinking and Drugs), are beginning to implement an intervention strategy which takes advantage of one of the primary means of communication for many youth and young adults—text messaging (33). One of their current strategies involves a text message system whereby youth in situations in which they are being pressured to use drugs or drink can send a text message to TADD members for guidance on what to do or for a clever response / strategy to get out of the situation (33). While the advice could be quite useful, just the process of texting back and forth alone might serve as enough of a diversion to help youth avoid a pressured situation. The communication strategy employed by TADD takes advantage of and is situated right within the context of youth norms around communication.
Working to change social norms one-by-one may not be an effective strategy to address teen substance use. The model employed by the “Truth” campaign’s demonstrates a way in which norms can be impacted as well as how they can become tools to further support a program’s intervention efforts in the way in which the program is framed or the channels of communication that are used. If used more broadly, these strategies could lead to more effective teen substance-use prevention programming.
While data had revealed that teen drug use was on the decline for years, recent trends show that this may no longer be the case. With that in mind, it is helpful to know what components are crucial to designing an effective drug intervention strategy. Examining the DARE program highlighted ways in which this model improved upon earlier efforts, but a closer examination revealed key areas in need of improvement. Based on that programmatic review, recommendations for alternative approaches were presented. These included a need for a perspective that takes into account macro-level factors, the developmental context of youth and the role of social norms. Keeping in mind these alternative approaches could enhance substance use prevention efforts for years to come.
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