POLICY STATEMENT

The Role of Schools in CombatingIllicit Substance AbuseCouncil on School Health and Committee on Substance Abuse

ABSTRACTDisturbingly high levels of illicit drug use remain a problem among Americanteenagers. As the physical, social, and psychological “home away from home” formost youth, schools naturally assume a primary role in substance abuse education,prevention, and early identification. However, the use of random drug testing onstudents as a component of drug prevention programs requires additional, morerigorous scientific evaluation. Widespread implementation should await the resultof ongoing studies to address the effectiveness of testing and evaluate possibleinadvertent harm. If drug testing on students is conducted, it should never beimplemented in isolation. A comprehensive assessment and therapeutic manage-ment program for the student who tests positive should be in place before anytesting is performed. Schools have the opportunity to work with parents, healthcare professionals, and community officials to use programs with proven effec-tiveness, to identify students who show behavioral risks for drug-related problems,and to make referrals to a student’s medical home. When use of an illicit substanceis detected, schools can foster relationships with established health care experts toassist them. A student undergoing individualized intervention for using illicitsubstances merits privacy. This requires that awareness of the student’s situationbe limited to parents, the student’s physician, and only those designated schoolhealth officials with a need to know. For the purposes of this statement, alcohol,tobacco, and inhalants are not addressed.

THE EFFECT OF SUBSTANCE ABUSE ON CHILDREN IN SCHOOLStudents spend the major part of their day in school. The school environmentprovides a standard against which young people test behavior.1 School personneloften serve as highly influential role models by which preadolescents and adoles-cents judge themselves. Adolescents who perceive that their teachers care aboutthem are less likely to initiate marijuana use, cigarette smoking, drinking to getdrunk, and other health risk behaviors.2 Relationships with teachers and counsel-ors are among the most important and formative ones for many students, espe-cially middle school students.2 Students who are poorly bonded to school are alsoless likely to recognize that substance use may reduce the likelihood of themachieving their future goals.3

The use of mind-altering chemicals has deleterious effects on school perfor-mance.4–7 Students under the influence of such substances are not ready to learnand are at risk of long-term impairment of cognitive ability and memory.7,8

Substance use is frequently associated with a lack of motivation and self-disciplineas well as reduced school attendance.9,10 Safety issues also are of concern. Mari-juana, like alcohol, is associated with increased risk of motor vehicle crashes and

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KeyWordssubstance abuse, drug, drug screens,adolescent, school health

AbbreviationAAP—American Academy of Pediatrics

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death.11–14 In addition, substance abuse is correlated withantisocial and violent behavior, such as bringing gunsand knives to school, as well as other risk-taking behav-iors.15–18

Schools, working in collaboration with communitypartners and health care professionals, are well situatedto identify students with signs and symptoms of illicitdrug abuse.19–21 Poor school performance, underachieve-ment, and truancy may be manifestations of substanceuse and indicate the need for evaluation and referral ofthese students to their medical home, where causes forthis behavior can be determined. Medical home provid-ers can use screening tools and resources available fromfederal, state, and local agencies, many of which arecategorized both geographically and topically on the In-ternet (see Fig 1).22

Although recent data have suggested that prevalenceof substance abuse has been decreasing in recent years,illicit substance abuse remains a major problem amongAmerican youth.23–26 The degree of illicit substance abuseamong students has translated into an ongoing societalsearch for ways to address this problem, including com-munity- and school-based prevention programs, stricterlaw enforcement techniques, and, more recently, theuse of laboratory testing programs within schools.

SCHOOL-BASED DRUG-SCREENING PROGRAMSIn June 2002, the US Supreme Court broadened theauthority of public schools to test students for illicitdrugs by allowing random drug testing for all middle andhigh school students who participate in competitive ex-tracurricular activities.27 Some schools and districts areperforming drug tests or are considering them for stu-dents in competitive sports, other physically active ex-tracurricular activities (eg, school band, cheerleading),and, in some cases, all extracurricular activities (eg,chess club, debate team). Students may be excludedfrom the activity until they have been cleared through ascreening process.28,29 The type of screening performedvaries widely (eg, urine, hair sample), as do the specificdrugs included in the screen and the response to a pos-itive drug-test result. Technical issues regarding illicitdrug testing are addressed in a separate American Acad-emy of Pediatrics (AAP) policy statement on drug test-ing30 and in a forthcoming addendum to that statementconcerning drug testing in schools and at home.31

Consequences of a positive drug-test result may in-clude punitive measures, further student assessment,counseling, therapy, and/or rehabilitation. Random drugtesting of students may affect specific students or groupsof students differently. The benefits and risks of drugtesting as a component of a comprehensive program toprevent or reduce substance abuse in such groups asnonusers, first-time and/or occasional users, and morefrequent or addicted users must be determined by scien-tific studies. Implementation of random drug testing of

students should await these results. The optimal meansof assessing the implications of a positive drug-test resultis an evaluation of the student by a health care profes-sional who is trained or experienced in this process.

Some societal leaders support broad drug testing as anaid in the prevention of drug use and possible earlyidentification of youth who have used drugs, therebyfacilitating appropriate assessment and therapeutic refer-ral. Others, including many parents and pediatricians,are concerned that school-based drug testing could un-necessarily label or stigmatize a child and compromisepersonal and family privacy. The Health Insurance Port-ability and Accountability Act applies to medical facili-ties, but children and adolescents do not have the samesafeguards to privacy of medical information in theschool. Recording positive drug-test results on students’permanent educational records (under guidelines of theFamily Educational Rights and Privacy Act), which areaccessible to many school personnel, could have nega-tive and long-term consequences. Strict attention to is-sues of confidentiality must be ensured.

It has not yet been established that drug testing doesnot cause harm. The following should be considered:

1. Students involved with illicit drugs may decreasetheir involvement in extracurricular activities to

FIGURE 1CRAFFT screening tool for adolescent substance abuse. (Reproduced with permissionfrom the Center for Adolescent Substance Abuse Research, Children’s Hospital Boston;2001.)

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avoid drug testing. According to the National Instituteon Out-of-School Time (www.niost.org), studentswho spend time in extracurricular activities are 49%less likely to use drugs. Without engagement in suchactivities, adolescents have a higher likelihood ofdropping out of school, becoming pregnant, joininggangs, pursuing or increasing their use of drugs,and/or engaging in other risky behaviors.32–34

2. Positive drug-test results may cause increased familyconflict rather than improve the home situation forthe student.

3. Drug testing of adolescents is not performed for pub-lic safety. Even adults have mixed responses to theidea of widely applied drug testing. Although manysupport the idea of drug testing as a necessary mea-sure for public safety from intoxicated or impairedpilots, bus drivers, police officers, and others, theyoften voice concerns when the application becomesmore pervasive and random.

4. Dollars spent on drug testing may be more effectivelyspent on drug prevention programs or well-estab-lished counseling programs.

5. Drug testing youth who have not been implicated inusing drugs may be perceived as being unfair and,thereby, may reduce trust and connectedness withtheir school, which are essential for maintaining linesof communication.2,33–35

Without evidence available to weigh the effectivenessof drug screening against the potentially harmful conse-quences, such programs should be limited in schools tothose that are carefully controlled and comprehensive inscope.36,37

DRUG EDUCATION AT SCHOOLSchools may adopt a variety of alternatives to drug test-ing to address the issue of substance abuse, includingoffering after-school programs, incorporating life-skillstraining into drug education curricula, helping parentsbecome better informed, providing counseling, identify-ing problem behaviors for early intervention, andpromptly referring students to health care professionalsfor assessment and intervention. School-based healthcenters should have the capacity to counsel studentswho are in need of such treatment plans and connectstudents to available community resources.

Schools are appropriate settings for drug preventionprograms for 3 reasons: (1) prevention must focus onchildren before their beliefs and expectations about sub-stance abuse are established; (2) schools offer the mostsystematic way of reaching young people; and (3)schools can promote a broad spectrum of drug-relatededucational policies.36 Resources for the preparation ofteachers, counselors, and other school personnel may bea valuable adjunct.19,20

Educators are challenged to make the facts about drugabuse meaningful to children and adolescents withoutenticing them to try drugs. There are many curriculadesigned for school use that have been proven to beeffective and are delivered to students in ways that areinteresting, interactive, and developmentally appropri-ate.36,38,39 Although many program approaches are avail-able, some effective programs focus on enhancing stu-dents’ problem-solving skills or aiding them to evaluatethe influence of the media. Other effective programshelp improve students’ self-esteem, reduce stress andanxiety, or increase activities. These skills are taught byusing a combination of methods including demonstra-tion, practice, feedback, and praise.40

Another proven approach is “life-skills training,” de-signed to teach skills to confront a problem-specificfocus, emphasizing the application of skills directly to theproblem of substance abuse. One of the most studiedprograms is LifeSkills Training (National Health Promo-tion Associates, White Plains, NY), a universal school-based prevention approach (most often focused on 7th-graders) that teaches general personal and social skillstraining combined with drug-refusal skills and norma-tive education. LifeSkills Training produces positive be-havioral effects on alcohol, tobacco, and illicit drug use.This approach, with booster sessions that follow theinitial program, is most effective.5 These effects continueyears after the intervention.36,41,42 Many effective curric-ula and drug prevention programs use interactive mate-rials and maximize group interactions with organizedactivities.36,38,39,43,44 Studies have demonstrated convinc-ingly that the effects of school programs can be amplifiedsubstantially when community components are added.20

PARTNERSHIP BETWEEN SCHOOLS, MEDICAL HOMEPROVIDERS, AND DRUG REHABILITATION PROGRAMSSchools may partner with rehabilitation programs toprovide care for a student to help successfully reintegratehim or her. Educational planning is an integral part ofafter-care contracts that pediatricians, mental healthprofessionals, or rehabilitation programs form with stu-dents and their families. The school’s roles in such acollaborative relationship include identifying any under-lying learning disabilities that may have contributed tothe problem, making special accommodations for stu-dents when necessary, providing remedial work so thatstudents can catch up with their classmates, helping toreinforce expectations for students to attend school andto comply with follow-up or monitoring as prescribed bythe health care professional or rehabilitation facility, andassisting with finding after-school programs. It is alsoimportant for students who have used substances to beassigned at least 1 trusted adult who is available in theschool building to help them if they feel they need it.Those who are assigned to work with the student’s drugproblems must know how to respect confidentiality of

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treatment. This adult or another school health profes-sional, school administrator, or designated staff membershould be assigned to work with the student’s pediatri-cian and rehabilitation personnel to communicate thestudent’s progress or failure to progress.

The roles of pediatricians, mental health profession-als, and rehabilitation programs in this collaborative re-lationship are to identify any mental health diagnosesand notify the schools of their relevance to the student’ssafety at school, to the student’s educational program,and to school personnel or operations in general. Healthcare professionals also need to provide schools withtreatment plans that may affect the school day whilemaintaining the student’s confidentiality to the extentthat is possible.

COMMUNITY COLLABORATIONWITH SCHOOLSCommunities can send a clear and consistent message bydeveloping and implementing a broad, comprehensiveapproach to dealing with substance abuse. Schools canserve as a focal point for such a community-wide effort.Community agencies can partner with schools to helpmonitor illicit drug use patterns in the local region todirect specific educational and preventive programs.Substance abuse problems that are associated with othermental health conditions can best be dealt with throughcomprehensive mental health programs that are capableof addressing prevention and intervention of both con-ditions. More information is available in the AAP policystatement on mental health in schools.45 School person-nel should receive ongoing training, preferably by ahealth care professional who is skilled at the recognitionof and risk factors for substance use and related disordersso that each staff member is able to guide faculty, par-ents, families, and others who are concerned about suchuse. As part of their community/school program tocounter substance abuse, the community should provideregular activities that are supportive alternatives to theabuse of drugs.

RECOMMENDATIONS FOR PEDIATRICIANSPediatricians should not support drug testing in schools.If testing is performed at all, it should only be done aspart of a funded, comprehensive approach to addressingsubstance abuse in the school and in the community.Examination of alternative approaches should be care-fully evaluated for effectiveness and cost.

Because of ongoing concerns about the implicationsof school-based drug-screening programs, the AAPmembership should support and promote alternativeschool-based efforts to combat substance abuse. In addi-tion, pediatricians should:

1. Serve as a medical home and resource for patientsand their families and offer primary (ie, universalapproaches designed to target all patients or potential

users before a problem occurs) and secondary (ie,approaches targeted at patients who have screenedpositive for high-risk behaviors such as tobacco, alco-hol, or inhalant use) prevention of illicit drug use.

2. Identify patients with personal, medical, mentalhealth, social, or academic problems who might be athigh risk for drug abuse. Consider the use of screen-ing tools and questionnaires, such as the Guidelinesfor Adolescent Preventive Services surveys (www.ama-assn.org/ama/pub/category/1980.html) and theCRAFFT tool,22 in the care of adolescent populationsto identify patients who might need additional assess-ment and treatment. Mental health problems such asanxiety, depression, attention-deficit/hyperactivitydisorder, and other diagnoses may coexist with sub-stance abuse. The patient’s progress should be mon-itored carefully so that ongoing assistance can beprovided.

3. Support communication strategies that maintain pa-tient/student confidentiality while coordinating treat-ment among the medical home provider, the family,and school-based programs.

4. Promote awareness of changing patterns of illicit druguse through local resources as well as through AAPchapter and district channels.

5. Raise awareness about mental health and rehabilita-tion services related to drug use that are availablewithin the community to aid the student, family, andschool.

6. Support and advise communities on the importanceof clear and consistent community-wide messagingon illicit substance use and the promotion of activitiesthat are free of drug and alcohol use.

7. Become familiar with the local school district’s sub-stance abuse prevention and health promotionprograms.

COUNCIL ON SCHOOL HEALTH 2005–2006

Barbara Frankowski, MD, MPH, ChairpersonRani Gereige, MD, MPHLinda Grant, MD, MPHDaniel Hyman, MDHarold Magalnick, MD*Cynthia J. Mears, DOGeorge Monteverdi, MDRobert D. Murray, MDEvan Pattishall, MDMichelle Roland, MDThomas L. Young, MD

CONSULTANT

Howard Taras, MD

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STAFF

Spencer Su Li, MPA

COMMITTEE ON SUBSTANCE ABUSE 2005–2006

Alain Joffe, MD, MPH, ChairpersonMarylou Behnke, MD*John R. Knight, MDPatricia Kokotailo, MD, MPHTammy Harris Sims, MD, MSJanet F. Williams, MD

CONSULTANT

Ed Jacobs, MD

STAFF

Karen Smith, MS

*Lead authors

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