A Qualitative Comparison of Parent and Adolescent Views Regarding Substance Use

Abstract

Substance use is a major cause of adolescent morbidity and mortality. By age 14, 70% of adolescents have consumed alcohol and half of 12th graders report having used marijuana. The purpose of this study was to increase the understanding of parent and adolescent perceptions regarding adolescent use of alcohol, tobacco, and other drugs (ATOD) to enhance the development of effective prevention programs. Six adolescent focus groups and one parent focus group participated. Results were derived following elicitation of adolescents' and parents' beliefs regarding adolescent ATOD use and current prevention programs. Findings indicate that current prevention programs are ineffective; ATOD use is normalized by schools, community, and family; positive adult role models deter use; and programs should involve youth, parents, schools, and community. Focus group discussions can strengthen the development of tailored ATOD prevention programs. School nurses can foster collaboration between families, schools, and communities to reduce adolescent substance use.

Keywords

alcohol/tobacco/drug use prevention middle/junior/high school qualitative research role promotion/development

Introduction

Adolescence is a time in life when many people first experiment with alcohol, tobacco, and other drugs (ATOD; Oman et al., 2004). Adolescence extends from the beginning of puberty (approximately age 11 in girls and 12 in boys) until an individual is physically and psychologically mature (Murray & Zentner, 2001). Findings suggest that the use of ATOD remains a normal part of American youth culture (Gatins & White, 2006) and may be perceived by youth as a normal rite of passage to adulthood. Despite some recently encouraging news showing a decline in selected ATOD use by adolescents, substance use continues to be widespread and a serious health concern in the United States (Skiba, Monroe, & Wodarski, 2004). Many school nurses recognize that substance misuse is a significant health problem for adolescents (Apa-Hall, Schwartz-Bloom, & McConnell, 2008).

Data indicate that youth continue to initiate substance-using behaviors at younger ages than many parents, school officials, and health professionals may suspect (Gatins & White, 2006). By the eighth grade, 22% of youth have tried cigarettes and 7.1% have become a current smoker (Johnston, O’Malley, Bachman, & Schulenberg, 2008). Nearly 39% of eighth grade students have reported drinking alcohol (Johnston et al., 2008) and 6% of eighth graders report having used marijuana in the last 30 days (National Institutes on Drug Abuse, 2008). Adolescents initiating early use of the gateway drugs, including alcohol, tobacco, and marijuana, have a greater risk for later substance abuse or for use of more harmful drugs (Hall & Lynskey, 2005; Kandel, 2002; Perry & Kelder, 1992; Skiba et al., 2004). Less than 1% of eighth graders reported injecting heroin during a 1-month period, while 15.6% reported inhalant use and 3.1% reported using cocaine (National Institutes on Drug Abuse, 2008). Initial and continued ATOD use among adolescents warrants the deliberate efforts of parents, schools, and professional communities to prevent substance use in this vulnerable group. The purpose of this qualitative study was to explore factors within a community contributing to adolescent substance use and evaluate current prevention programs to guide the development of strategies to effectively deter ATOD use.

A modest decline in marijuana use by adolescents was reported in 2007. This decline is significant because marijuana use is the barometer estimating overall drug use in adolescents. Prevalence rates for marijuana use are 10.3%, 24.6%, and 31.7% in 8th, 10th, and 12th graders, respectively (Johnston et al., 2008). Alcohol use continues to be extremely widespread; 72% of 12th graders reported drinking alcohol in the preceding month (Johnston et al., 2008). Of concern, 18% of 8th graders and 55% of 12th graders reported having been drunk at least once (Johnston et al., 2008). Use of the prescription narcotics oxycontin and vicodan remains consistently high with over 5% of high school seniors having tried oxycontin and nearly 10% have tried vicodan. Annual prevalence rates for 8th and 10th graders having tried the narcotic vicodan are 2.7% and 7.2%, respectively. The use of prescription narcotics may be perceived as “safe” by adolescents because these drugs are prescribed as medical or dental treatments. Illicit opiate use has been associated with earlier progression to heroin and injection drug use (Grau et al., 2007; Johnston et al., 2008).

In general, ATOD use increases with age from 8th through 12th grade with the exception of inhalants, which typically are used more by younger adolescents (O’Malley, Johnston, Bachman, Schulenberg, & Kumar, 2006). Since 2003, inhalant use has increased in 8th, 10th, and 12th graders, reflecting a group cohort effect by progressing along the age spectrum (Johnston et al., 2008). In 2006 and 2007, the use of inhalants declined in 8th and 12th graders but not in 10th graders (Johnston, O’Malley, Bachman, & Schulenberg, 2006). This upward trend in inhalant use is linked to generational forgetting, suggesting that younger youth perceive less risk in some drugs because they have not heard of the dangerous consequences associated with the drug (Johnston et al., 2006). Generational forgetting may lead to the resurgence of some previously popular and dangerous drugs (Johnston et al., 2006).

ATOD use has an extraordinary impact on the morbidity and mortality of youth. The leading causes of death among those aged 12–17 years in the United States are motor vehicle crashes, homicide, and suicide, all of which are related to substance use (Kaye, 2004). Alcohol use is a predictor of early sexual activity and failure to use condoms, leading to unplanned teenage pregnancy and sexually transmitted diseases, including HIV (Loveland-Cherry, 2000). Negative health outcomes and associated costs attributed to adolescent drug use affect nearly 500,000 individuals a year (Johnston et al., 2006). Economic costs of smoking and the use of alcohol and illegal drugs were estimated to reach $484 billion in 2004 (Centers for Disease Control and Prevention, 2004).

“ATOD use has an extraordinary impact on the morbidity and mortality of youth.”

A number of prevention programs have been designed to discourage or reduce adolescent substance use. Approximately 90% of U.S. schools report inclusion of information or skills training in the curricula related to prevention of substance use (Kann, Brener, & Wechsler, 2007). Adolescent drug prevention programs are diverse and may target the school environment, academic performance, problem-solving and social abilities of the youth, parenting skills, and community norms (Arthur & Blitz, 2000; Perry et al., 1996). Peer, school, home, and neighborhood/community environments have been identified as potential sites for delivery of adolescent drug prevention programs (Fitzgerald & Arndt, 2002). The best approach to prevent adolescent substance use remains unclear. Previous research indicates that adolescent substance use prevention programs may be most effective when designed to meet the needs of a specific community (Arthur & Blitz, 2000). The purpose of this study was to identify key factors contributing to adolescent substance use within a given community to guide planning and implementation of effective prevention programs. The trusting relationships the school nurse has established with adolescents and within schools in the community can facilitate the development of effective and collaborative ATOD prevention programs (Apa-Hill et al., 2008).

Research has found both risk and protective factors that influence adolescent ATOD use. Family, peer, and other social relationships appear to have a strong influence on adolescents' substance use behavior. Family communication and parenting behaviors can either positively or negatively influence adolescent decisions related to substance use (Gatins & White, 2006; Hawkins, Catalano, & Arthur, 2002; Highet, 2005; Jessor, Turbin, & Costa, 1998; Kegler et al., 2002; Mishra et al., 2005; Scheer, Borden, & Donnermeyer, 2000). Positive family dynamics, parental monitoring, and achievement-focused values serve as protective factors that reduce adolescent substance use (Oman et al., 2004). Having family and/or peers who model healthy behaviors may serve as a protective factor for adolescent substance use (Jessor et al., 1998). In contrast, permissive parental attitudes and behaviors toward substance use may promote substance use in adolescents (Hawkins et al., 2002). Peer influences and the belief that ATOD use is a normal part of being a teenager are also factors that promote ATOD use (Gatins & White, 2006).

Likewise, the school environment plays a major role in the development of risky ATOD behaviors (Abrams & Clayton, 2001). Peer interactions, transitions in relationships, and school achievements are factors that can influence youth ATOD use (Abbey, Pilgrim, Hendrickson, & Buresh, 2000). Availability of school and community activities in which adolescents can participate has been found to deter ATOD use (Tuttle, Campbell-Heider, & David, 2006; Tuttle, Melnyk, & Loveland-Cherry, 2002). Previous research indicates that variance in ATOD attitudes and behaviors in youth is dependent on certain school characteristics, including grade level, public or private school, and the socioeconomic status and race/ethnicity of the students (O’Malley et al., 2006). Most U.S. schools have substance use policies, although the policies vary widely in terms of ATOD restrictions and enforcement of behavior (Evans-Whipp, Beyers, Lloyd, Arthur, & Catalano, 2004). Little evidence exists supporting the relationship between specific substance use school policies and the reduction of substance using behaviors (Evans-Whipp et al., 2004; O’Malley et al., 2006). Although research has conceptualized some of the factors within schools and communities that influence adolescent ATOD use, few studies have examined in depth the knowledge, attitudes, and beliefs of parents and adolescents and their perceptions of ATOD prevention programs in their schools and community.

“Peer interactions, transitions in relationships, and school achievements are factors that can influence youth ATOD use.”

Several qualitative studies have focused on parents' knowledge, attitudes, and beliefs regarding alcohol, tobacco, and/or marijuana use by youth (Graham, Ward, Munro, Snow, & Ellis, 2006; Kegler et al., 2002). Findings indicated that parents perceived that local communities accept and tolerate adolescent ATOD use and that this indifference fostered a general propensity for substance use among adolescents. Parents perceived that the community’s acquiescence to adolescent ATOD use would be very difficult to change (Graham et al., 2006; Kegler et al., 2002; Rogers & McCarthy, 1999). Although parents worried about immediate dangers from alcohol, tobacco, or drug use, few were concerned about the long-term risks of adolescent substance use (Graham et al., 2006). Other focus group study findings suggest that both peer influences and youth curiosity affect smoking and drug use behaviors (Balch et al., 2004; McIntosh, MacDonald, & McKeganey, 2003). A need exists to obtain comprehensive information identifying key factors that positively and/or negatively influence adolescent substance use within a specific community to develop effective ATOD prevention programs.

The purpose of this qualitative study was to gain an in-depth understanding of parent and adolescent perceptions regarding ATOD use and current ATOD prevention programs within schools and the community. Findings were used by a regional coalition of agencies to develop a school-based prevention program for a six-county region of a Midwestern state. This study was conducted with funding from the State Incentive Cooperative Agreement (SICA). Human rights approval for the study was obtained from the designated Institutional Review Board.

Methods

Parent and adolescent focus groups were conducted separately to elicit perceptions of issues, programs, and experiences regarding ATOD use among adolescents and previous prevention programs. Focus groups were conducted in relaxed, informal community settings to encourage spontaneous expression of ideas among group participants (Krueger & Casey, 2000). A study plan was used to enhance adolescent and adult focus group discussions to obtain the desired results (see Table 1 ). The plan reflects factors important in working with adolescents, such as peer influences, age-related developmental and gender differences, and a casual, nonthreatening environment (Krueger & Casey, 2000; Wyatt, Krauskopf & Davidson, 2008). Adolescents (12–19 years old) were divided into separate groups according to gender and by a 2-year age span for a total of six groups. The parent focus group included at least one parent from all of the adolescent age groups.

Table 1.

Planning Phases and Considerations for Focus Groups With Adolescents and Parents

Planning Phase	Considerations
Determining the structure	Number of groups Physical locations Group composition Length of groups Time order
Recruitment of participants	Use of key contacts and “snowball” technique Determined by location in the region
Development of moderator script	Analysis of coalition meeting input Type of questions by theme Order of questions Age-specific variations Assurance of confidentiality and ground rules
Group setting	Room layout to facilitate dialog Relaxed, informal setting Preferred food and beverages
Data collection process	Professional recording equipment Flip charts Research team roles: moderator, recorders Debriefing sessions
Data analysis	Use of professional transcriptionist Cleaning the transcription Building the coding hierarchy Use of NVivo software Coding process Analyzing data by individual researchers and by consensus Saturation point

Setting

The targeted region for this study was the six-county region served by the community-based coalition. The six counties range in population from 20,000 to 498,000 dispersed around a large metropolitan area. The total population of the targeted area is approximately 725,000. Although parts of these counties consist of small towns and rural areas, much of the targeted region is considered urban or suburban.

Sample

Adolescent and parent participants were purposively recruited from the targeted region using key contacts (Polit & Beck, 2004). Key contacts are an essential link to the population of interest and facilitate the recruitment of participants who will provide meaningful data (Polit & Beck, 2004). The four adult key contacts lived in the targeted region, were members of the six-county coalition, and represented local public or private schools (teachers or administrators) or other community organizations. The key contacts recruited participants from their respective schools whom they believed best represented the desired sample in terms of age, gender, and race and who had the ability to meaningfully contribute to a focus group. Both fathers and mothers of adolescents were invited by key contacts to participate in the parent session. The key contacts also used snowball-style recruiting, one participant finding another participant (Speziale & Carpenter, 2007), in an effort to recruit an adequate and representative sampling of the region. This technique maximizes the familiarity factor and facilitates participant interaction within the groups, often important in recruiting adolescent participants, but may limit the breadth of the data (Speziale & Carpenter, 2007).

The study team sent 25 letters of consent to potential parent participants and 56 letters of assent or consent to adolescents and their legal guardians guided by the recommendations of the key contacts. The number of invitation letters mailed varied per focus group but range between 13 and 25 (parent group) letters per focus group. Letters contained all elements of informed consent and meeting information. One phone call was made to potential participants or their guardians 1 week after they received the letter, verbally inviting them to participate in the appropriate focus group. Incentives for study participants included a monetary payment ($20), a light meal and, for the parent group, child care. Each focus group was held in a centrally located neutral, nonthreatening setting.

Forty-eight adolescents, aged 12 to 19 years, participated with an average of eight participants per adolescent group. Among the adolescents, 88% were Caucasian (83.4% Caucasian in region), 9% Black (11.7% Black in region), and 3% Hispanic (9.4% Hispanic in region) and 59% were female. The racial distribution among adolescent participants was similar to the distribution in the community with the greatest difference among Hispanic. Among youth, 79% attended public schools, 13% attended private school, and two students were homeschooled. Sixty-five percent of the adolescents lived with two parents, consistent with 2008 U.S. Census data reporting that 70% of youth live with parents. The remainder of the youth reported living with a single parent or a family member. Parents were recruited by school officials associated with the LiveWise coalition. The parent group consisted of 11 women who had at least one child between the ages of 12 and 19 years currently enrolled in a local public or private school. Eighty-one percent of the parents were Caucasian and 19% were Black, while no Hispanic parents volunteered. The majority of parents (73%) were married.

Procedure

Focus group questions were developed based on the major findings from a previous ATOD survey of local households (Cramer et al., 2005) and with input from members of the community coalition. Similar questions were used for the parent and adolescent focus groups to guide discussions. 9In an effort to promote discussion and to avoid disclosure of sensitive personal information, questions were asked regarding what others (adolescents or parents) might do related to ATOD use (see Table 2 ). Prior to data collection, the focus group moderator explained the purpose of the session, the ground rules, appropriate conduct, and methods to assure anonymity of participants. Each participant completed a brief demographic form.

Table 2.

Focus Group Discussion Questions

Describe your (your child’s)a experiences with antidrug and alcohol programs at school. Were the programs effective or ineffective? Explain your response.

What prevents the people of your (your child’s) age from using alcohol, tobacco, or other drugs (ATOD)?

Where do(es)^a you (your child) get information about drug and alcohol prevention?

What do(es) you (your child) think makes people start to use alcohol, tobacco, or other drugs?

Why do(es) you (your child) think teens use ATOD even though they believe it is very wrong?

What makes people of your (your child’s) age continue to use ATOD?

What external things allow guys/girls your (your child’s) age to continue to use?

What internal influences allow guys/girls your (your child’s) age to continue to use?

How do people of your (your child’s) age who use ATOD get access?

Where, when, and with whom do people of your (your child’s) age use ATOD?

Imagine high school seniors on the weekend. What do(es) you (your child) see them doing? What do(es) you (your child) think the high school seniors do for fun?

What would you like to know about alcohol, tobacco, and marijuana? Anything at all …

Who do you think is responsible for telling you (your child) about ATOD?

What is the most important thing parents (you)a can do to prevent youth from using ATOD?

What can schools do to prevent adolescents from using ATOD?

If you could design the ideal antidrug program, what would it be like?

Describe who would teach the program?

When would you like the programs?

If you could say one thing to adults who design antidrug and alcohol programs, what would you want them to know?

^a Adapted for parent focus groups.

Analysis

At the close of each focus group session, participants' responses were summarized to help assure saturation and check validity of data. Data for each focus group were transcribed, coded, and analyzed separately using NVivo qualitative analysis software (NVivo7, 2006). Responses to each research question were organized such that the most frequent or universal answers were labeled as a group response. Analysis was performed initially by an individual researcher and later with research team collaboration to identify common answers to each focus group question. The use of individual and group consensus provides validity to the data and therefore limits the ability to determine the number of participants who responded to each individual research question. Following these analyses, study results and implications were disseminated to the community coalition to guide development of ATOD prevention programming.

Results

Responses to each research question (see Table 3) as identified by parents and youth are as follows:

Table 3.

Findings

Themes/Subthemes	Study Findings	Exemplars
1. Perceptions of current ATOD prevention programs	Youth described ATOD programs overall as: Being too infrequent Targeting primarily younger youth while ignoring older teens' increased need Ineffectively affecting youth’s ATOD attitudes and behaviors Being outdated, irrelevant, and boring for youth Youth expressed need for more frequent and relevant programs Parents felt detached and wanted opportunities to network at school with other parents	Youth 9th–10th grade male—“I remember a lot of stuff in fifth, sixth, seventh, and eighth grade. But I don’t think that’s the right time to be cramming that into your head ‘cuz that’s not really when it’s (ATOD use) happening. It’s all in high school where it’s mostly happening.” 11th–12th grade male—“I don’t think they do enough at our school to make it extremely effective.” Parent—“You think, ‘Okay, there's another connection’. And you can say to that other parent, ‘You call me if you find any thing that you think is wrong. You call if you think my son has been drinking. Just call.”
2. Factors that promote ATOD use in the community	Both youth and parents described the following as promoting factors: Extreme nature of normalizing ATOD use in our culture Family culture Family situations and relationships Strong peer influences Being labeled by peers as an “ATOD user” Receiving mixed messages from parents, school personnel, and the culture Perceiving double standards about ….	Youth 9th–10th grade male—“The whole concept of parties involving alcohol. It’s not a party unless alcohol, seems like that’s always in the movies, TV and stuff.” 9th–10th grade female—“Our school doesn’t do well …. They set the rules, but not everyone follows them, and they do enforce them, but they don’t enforce them as well as they should ….” 9th–10th grade male—“If you’re brought up in a family with smokers and alcoholics, then you’re more susceptible to it.” Parent—“I think kids model what they see, those parents who are trying to be their friends and letting them drink ….”
Subtheme: Youth use of ATOD	Youth have an easy access to ATOD Older peers, coworkers, and family (including parents) procure ATOD for youth ATOD use in homes and schools	Youth 9th–10th grade male—“I think it’s really easy to get anything if you know the right people ….” 11th–12th grade male—“You’re just hanging out with your friends in the basement. And you think …. How can we possibly get in trouble? So they’ll just bring a bottle down and you start drinking.” 11th–12th grade female—“People will drink Gatorade bottles full of vodka between classes.” Parent—“Oftentimes when parents talk about preventing youth from drinking alcohol, we don’t realize it’s in our house and it’s not locked.”
3. Factors that prevent Youth ATOD	Youth reported the following factors as deterring use: Fear of consequences; desire not to disappoint parents; punishment from parents, school, or legal consequences; injuries, chronic disease, and death Effects of using ATOD on family life Negative aesthetic effects and banned or reduced athletic performance Impede attainment of life goals	Youth 11th–12th grade male—“… personally just seeing like what, alcohol can do to a family like, if alcoholism runs in your family, obviously you don’t want to start it. Just see it like, tears a family apart so.” 7th–8th grade female—“One of my friends, her cousin died, um he was like drunk and he drove off a cliff ….” 11th–12th grade male—“He got involved in a lot of bad [cigarettes and alcohol] stuff, and quit everything, he was a good athlete and stopped playing every sport that he ever played and now he looks horrible ….” 11th–12th grade male—“Well I think the biggest prevention with some of my friends is probably they won’t do anything with drugs or alcohol while they’re in sports, a varsity sport.” 9th–10th grade male—“I wouldn’t use because it would be staying on your record.”
4. Ideal ATOD drugs prevention programs	Youth reported program could be improved by: Being up-to-date, engaging in age-appropriate programs appealing to emotional domain More involvement from the community, school, media, and parents involved Credible speakers with real-life experience Parenting skills training in setting behavior guidelines/boundaries and responsible modeling Opportunities to learn from mistakes	Youth 9th–10th grade female—“Drugs and whatnot, you know, everybody should be telling you about that.” 9th–10th grade male—“I think real life examples would be a lot more beneficial in prevention and stuff than just a bunch of facts and stats …..” 11th–12th grade male “One of the things that helps stop people from drinking is when parents wait up for you. My mom always waits up for me to come home, and she’ll usually talk to me so, obviously, I’m not gonna come home super drunk.” Parent—“I mean it takes a village …. See, it takes all of us.” Parent (high school teacher)—“I think parents have good intentions most of the time, but like we’ve already said over and over, they want to be their friend. It’s like my coworkers (teachers) who want to be their friend.”

Research Question 1: Perceptions of Current ATOD Prevention Programs

Adolescents

Across all ages, the majority of participants recalled having received ATOD prevention education during their elementary and middle school education. The Drug Abuse Resistance Education (D.A.R. E.) program was the most commonly cited drug prevention education program although adolescents stated that some teachers provided drug information in class. Older adolescents stated that ATOD prevention programs were infrequent in high school, even though participants identified a greater need for ATOD prevention programs in the upper grades. Most ATOD prevention programs in high school were perceived as ineffective and too infrequent and were either all-school assemblies or attempts to enforce drug-free policies. Older adolescents stated that ATOD prevention programs in school had little impact on attitudes or behaviors regarding ATOD use and felt the programs were boring, outdated, and irrelevant.

Parents

Parents' understanding of current ATOD prevention programs varied widely. Most parent participants reported attending school-sponsored ATOD programs, yet a few had minimal information regarding such programming. Despite the lack of information, parents believed that school-sponsored programs for all adolescents would be helpful.

Research Question 2: Risk Factors Promoting ATOD Use

Adolescents

All participants stated they received mixed messages and double standards about ATOD use from the media, their family, and schools. Adolescents recognized the inconsistencies associated with ATOD use, such as the perception that alcohol use is acceptable on holidays or at family functions. Most participants reported that some school officials punish students inequitably when caught using ATOD, depending on biases regarding the individual’s or the family’s status in the school or community.

Regardless of their age, most participants of all age groups talked about wanting their parents to be parents by serving as positive role models, providing guidance regarding ATOD, and establishing consistent behavior expectations. Adolescents did not want parents or other adults to act like friends but to help them develop responsible attitudes and behaviors toward ATOD use.

Adolescents identified key factors that actively promote ATOD use. Factors identified include the pervasive national and local cultures that normalize ATOD use, by making it appear that “everyone [in the community] our age does it.” Additionally, permissive parent/family attitudes, poor parenting, and certain family characteristics tend to promote ATOD use. Most adolescents were adamant that parents should not allow youth to use ATOD at home because doing so portrays a permissive attitude resulting in negative consequences for them and their friends. Adolescents noted that peer pressure to use ATOD does exist but varies across age groups. Middle school students reported less peer pressure to use ATOD, while high school students, especially 9th and 10th graders, felt strong peer pressure.

“Most adolescents were adamant that parents should not allow youth to use ATOD at home because doing so portrays a permissive attitude resulting in negative consequences for them and their friends.”

Parents

All parents believed that adolescents are strongly influenced by peer pressure to use ATOD and that youth willingly comply in an effort to be part of the group. Parents expressed little concern over their own roles in promoting ATOD use but strongly disapproved of other parents who allow youth to use ATOD in their homes.

Probing Question: Access and ATOD Use

Adolescents

Nearly all participants reported easy access to ATOD: “All you need is money and to know the right people.”

All participants reported getting ATOD from someone they know, especially older peers and family members and parents (with or without the parent’s knowledge). These findings are consistent with the 2005 Parent and Youth Household Survey (Cramer et al., 2005). Older adolescents did not view tobacco as a drug, because they were of legal age (or near) to purchase tobacco products. Seventh/eighth graders viewed tobacco as a drug similar to alcohol or marijuana.

All participants reported that the primary place for ATOD use was either their homes or a friend’s home, and the school/school grounds were common sites for ATOD use. Nearly all of the participants stated they had observed peers using ATOD at school before, during, and after classes. Participants shared instances when peers were under the influence of ATOD while attending school.

Parents

Parents expressed concern to the point of anger that “those other parents” allow youth to use ATOD in their homes, stating that this practice is both dangerous and illegal. Participants did not allude to the possibility that their child and other adolescents might be accessing and using ATOD in their homes.

Research Question 3: Protective Factors Preventing ATOD Use

Adolescents

All participants agreed that a major deterrent to ATOD use is the fear of punishment from parents, schools, and law enforcement. The most significant deterrent from ATOD use was the fear of negative consequences that could result, such as jail or criminal record, school sanctions (banning from sports or other school activities), dying from overdose and/or motor vehicle crashes, and ruining their future career choices. Another deterrent cited by adolescents, especially females, was the negative effects that ATOD would have on their physical appearance, such as yellow teeth and emaciation that could result from methamphetamine use. Several participants involved in sports voiced concerns over the deleterious effects smoking or drugs would have on their athletic performance. Adolescents shared that positive peer pressure to avoid using ATOD usually came from members of their sports teams.

The desire not to disappoint or lose the respect and trust of their parents was a deterrent to ATOD use cited by the older adolescents. Participants discussed the importance of parents openly communicating with their children, setting firm boundaries and expectations and modeling responsible behavior. Most adolescents felt parents play a major role in preventing ATOD use by monitoring their child’s behavior, actions, friends, and whereabouts and in building parental networks. A few participants also discussed the possibility that parents who irresponsibly use ATOD may actually deter ATOD use by their children. One ninth/tenth grade female commented:

If your parents do the drugs and drink all the time, constantly, you’re gonna be one of the kids that are like “I’m not gonna do it.”

Parents

Unlike the youth, all parents believed that youth felt fearless and invincible with the attitude:

It’s not going to happen to me.

Parents did not think the youth’s fear of negative consequences was as powerful a deterrent to ATOD use as the youth had expressed.

Research Question 4: Ideal ATOD Prevention Programs

Adolescents

All participants believed schools were important in providing ATOD prevention information on a regular basis from elementary through high school. The strongest message shared by adolescents was that ATOD prevention programs be delivered by credible, experienced sources, rather than classroom teachers. Adolescents prefer interactive and emotive programs delivered by someone close to their age with personal, thought-provoking experiences related to ATOD use.

Parents

Parents wanted more ATOD information from the schools to better understand the problem, including ATOD use statistics in the local community. Parents wanted schools to provide parenting skills training, focusing on setting, and maintaining behavioral boundaries for adolescents and to help in developing effective communication networks for parents.

Discussion

Study findings indicate that adolescents of all ages want more prevention programs at school and through all grades but most especially in their transition from middle to high school when peer pressure is reported to be the strongest. Previous research supports this finding, indicating middle school students report higher ATOD use rates than elementary or high school students and may have the greatest need for ATOD prevention programs (Marsiglia, Holleran, & Jackson, 2000). Although specific information on previous drug prevention education was not elicited in this study, adolescents believed that current ATOD prevention programs are outdated and ineffective. Adolescents want programs to be relevant to their age, emotive, and offered by persons they view as credible or experienced in ATOD. Parents agreed that ATOD prevention programs are not effective, and consistent with other research (Graham et al., 2006; Rogers & McCarthy, 1999), many parents were unaware of current ATOD programs offered by the schools. Parents expressed the need to know the extent of ATOD use by youth in the community and wanted more information to help in understanding the issues.

Parents in this study believed that peer pressure was extremely strong in promoting ATOD use; however, adolescents did not suggest that peer pressure is a predominant influence on their decision to use ATOD, except during the early high school years (9th and 10th). Some research findings indicate that parents believed peer pressure to use ATOD is strongest for younger adolescents (Graham et al., 2006), while other findings show peer pressure for ATOD use is particularly influential in middle school students (Marsiglia et al., 2000). Consistent with this study, previous research has indicated that younger adolescents who report peer pressure has only a modest impact on their actual ATOD behavior and initial experimentation is usually related to curiosity (McIntosh et al., 2003).

Consistent with previous research, the current study findings support the importance of school and community activities, especially sports, as a way to engage students and deter substance use (Costa, Jessor, & Turbin, 1999; Jessor et al., 1998). In contrast, some research has linked playing high school sports with increased alcohol use (Eitle, Turner, & Eitle, 2003). Parents in this study also believed the school and community are major influences on ATOD access and use by adolescents.

Parental and family relationships were perceived to be a major influence on ATOD use. Contrary to what parents believed, adolescents wanted their parents, teachers, and other adults to be effective role models, responsibly guiding their decisions regarding ATOD use. Parents and adolescents agreed that parental attitudes and behaviors regarding ATOD use are a strong influence on adolescent ATOD use. Adolescents reported they respect parents who set boundaries, monitor their teens' behavior, and enforce sanctions fairly. A positive parent–child relationship and effective parenting skills have been identified as factors that deter adolescent substance use (Oman et al., 2004). Adolescents expressed their desire for “parents to be parents” rather than trying to be their friend, which only tends to foster their ATOD access and use.

Findings indicate a dissonance between what youth know about access and use of ATOD and what parents believed. Adolescents reported that ATOD is easily obtained and is predominantly used in homes, including their homes. Parents recognized that other parents procure ATOD for youth and allowed them to use it in their homes. However, parents denied the possibility that their own homes could be a site of ATOD access or use. Parents expressed the need for more local information regarding adolescent ATOD use, raising their awareness of the problem and trends in substance use in the community. Consistent with other research (Graham et al., 2006), parents in this study requested open communication and networking channels with other parents and schools to help reduce adolescent ATOD use.

Adolescents emphasized that sanctions for ATOD use would significantly deter substance use. The fears of negative consequences associated with ATOD use relative to their personal appearance, athletic performance, reputation, and future opportunities would be important factors to include when designing substance use prevention programs and community-based media campaigns. These parents recognized their limitations in setting boundaries and enforcing sanctions for ATOD use. Parents requested parent skills training to effectively monitor their adolescents' behavior and role-modeling responsible behavior related to the use of substances. Parent effectiveness training has been identified as an important factor in facilitating modification of adolescent behaviors (Riggs, Elfenbaum, & Pentz, 2006). Because only mothers attended this parent session, input from fathers would be valuable in gaining their perceptions related to the father’s role in preventing adolescent ATOD use.

Adolescents described the pervasive societal norm of ATOD use that is accepted by members of the community. This was not a factor that the parents discussed. Community acceptance and normalization of ATOD behaviors allude to a culture fostering ATOD use. Culture has been found to play a significant role in adolescent ATOD use in other communities (Graham et al., 2006). Efforts to minimize adolescent ATOD use would be enhanced by implementation at the community level, as well as in schools and families (Arthur & Blitz, 2000). Strategies to denormalize the use of ATOD among adolescents are important in reducing the substance-using expectations adolescents often perceive to be present. Media messages are needed to negate the belief that adolescents can use ATOD without resulting consequences. Findings indicate that parents want stronger legal and societal sanctions for adults who procure ATOD for youth. Adolescents and parents felt that authority figures, including school officials and law enforcement, must be consistent and impartial in punishing youth for ATOD use.

“Community acceptance and normalization of ATOD behaviors allude to a culture fostering ATOD use.”

Limitations

Although the sampling method was designed to provide for groups of adolescents and parents who represented the community, the participants were predominantly Caucasian and lived in middle-income neighborhoods with underrepresentation particularly among Hispanics. The projected sample was recruited from schools and neighborhoods with diverse inhabitants to provide proportionate numbers of racial/ethnic minorities and various socioeconomic levels living in the region. Another limitation is that the parent focus group consisted only of mothers of adolescents; although several fathers were recruited and consented, no fathers attended the session. The parent session was prearranged and scheduled during evening hours, but special recruiting strategies and accommodations for fathers might have enhanced their attendance. Because the study sample was from a specific region in the United States, these findings may differ from focus group results obtained in another part of the country.

Implications for School Nurses

School nurses fulfill an important role in coordinating school and community efforts to develop collaborative substance use prevention programs. This study could be replicated in other schools and communities to determine adolescents' and parents' beliefs regarding current ATOD prevention programs. Nurses can foster open communication between adolescents, families, and the schools and community to effectively manage the problem of adolescent substance use. School nurses have the necessary skills to effectively modify factors that tend to promote ATOD use by adolescents.

Specifically, the school nurse can provide adolescents with effective strategies to resist negative peer pressure that promotes ATOD use. Although the specific impact school and community involvement has on ATOD use is not clearly delineated, the nurse can promote youth involvement in creditable school and community activities. Nurses can provide parents with information on available ATOD prevention resources and foster open communication by providing them with the contact information of other parents and school officials. Nurses can educate parents with the necessary information and skills training to effectively monitor and guide their child’s behavior. Nurses should advocate for consistent policies that strengthen consequences for adolescent ATOD use and firm penalties for adults procuring ATOD for adolescents. School nurses can recommend increasing the number and frequency of ATOD prevention programs, particularly targeting high school students and tailoring programs specific to the age and grade-level of the adolescent.

In conclusion, findings from this focus group study present insightful information to guide future adolescent ATOD prevention programming in schools and the community. The methods used to conduct this study can serve as a guide for other schools and community partners to gain a thorough understanding of parent and adolescent knowledge, attitudes, and beliefs of adolescent substance use.

Footnotes

Notes

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