Disturbingly high levels of illicit drug use remain a problem among American teenagers. As the physical, social, and psychological “home away from home” for most youth, schools naturally assume a primary role in substance abuse education, prevention, and early identification. However, the use of random drug testing on students as a component of drug prevention programs requires additional, more rigorous scientific evaluation. Widespread implementation should await the result of ongoing studies to address the effectiveness of testing and evaluate possible inadvertent harm. If drug testing on students is conducted, it should never be implemented in isolation. A comprehensive assessment and therapeutic management program for the student who tests positive should be in place before any testing is performed. Schools have the opportunity to work with parents, health care professionals, and community officials to use programs with proven effectiveness, 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 substance is detected, schools can foster relationships with established health care experts to assist them. A student undergoing individualized intervention for using illicit substances merits privacy. This requires that awareness of the student's situation be limited to parents, the student's physician, and only those designated school health 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 SCHOOL
Students spend the major part of their day in school. The school environment provides a standard against which young people test behavior.1 School personnel often serve as highly influential role models by which preadolescents and adolescents judge themselves. Adolescents who perceive that their teachers care about them are less likely to initiate marijuana use, cigarette smoking, drinking to get drunk, and other health risk behaviors.2 Relationships with teachers and counselors are among the most important and formative ones for many students, especially middle school students.2 Students who are poorly bonded to school are also less likely to recognize that substance use may reduce the likelihood of them achieving their future goals.3
The use of mind-altering chemicals has deleterious effects on school performance.4–7 Students under the influence of such substances are not ready to learn and 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-discipline as well as reduced school attendance.9,10 Safety issues also are of concern. Marijuana, like alcohol, is associated with increased risk of motor vehicle crashes and death.11–14 In addition, substance abuse is correlated with antisocial and violent behavior, such as bringing guns and knives to school, as well as other risk-taking behaviors.15–18
Schools, working in collaboration with community partners and health care professionals, are well situated to identify students with signs and symptoms of illicit drug abuse.19–21 Poor school performance, underachievement, and truancy may be manifestations of substance use and indicate the need for evaluation and referral of these students to their medical home, where causes for this behavior can be determined. Medical home providers can use screening tools and resources available from federal, state, and local agencies, many of which are categorized both geographically and topically on the Internet (see Fig 1). 22
Although recent data have suggested that prevalence of substance abuse has been decreasing in recent years, illicit substance abuse remains a major problem among American youth.23–26 The degree of illicit substance abuse among students has translated into an ongoing societal search for ways to address this problem, including community- and school-based prevention programs, stricter law enforcement techniques, and, more recently, the use of laboratory testing programs within schools.
SCHOOL-BASED DRUG-SCREENING PROGRAMS
In June 2002, the US Supreme Court broadened the authority of public schools to test students for illicit drugs by allowing random drug testing for all middle and high school students who participate in competitive extracurricular activities.27 Some schools and districts are performing drug tests or are considering them for students in competitive sports, other physically active extracurricular activities (eg, school band, cheerleading), and, in some cases, all extracurricular activities (eg, chess club, debate team). Students may be excluded from the activity until they have been cleared through a screening process.28,29 The type of screening performed varies widely (eg, urine, hair sample), as do the specific drugs included in the screen and the response to a positive drug-test result. Technical issues regarding illicit drug testing are addressed in a separate American Academy of Pediatrics (AAP) policy statement on drug testing30 and in a forthcoming addendum to that statement concerning drug testing in schools and at home.31
Consequences of a positive drug-test result may include punitive measures, further student assessment, counseling, therapy, and/or rehabilitation. Random drug testing of students may affect specific students or groups of students differently. The benefits and risks of drug testing as a component of a comprehensive program to prevent or reduce substance abuse in such groups as nonusers, first-time and/or occasional users, and more frequent or addicted users must be determined by scientific studies. Implementation of random drug testing of students should await these results. The optimal means of assessing the implications of a positive drug-test result is an evaluation of the student by a health care professional who is trained or experienced in this process.
Some societal leaders support broad drug testing as an aid in the prevention of drug use and possible early identification of youth who have used drugs, thereby facilitating appropriate assessment and therapeutic referral. Others, including many parents and pediatricians, are concerned that school-based drug testing could unnecessarily label or stigmatize a child and compromise personal and family privacy. The Health Insurance Portability and Accountability Act applies to medical facilities, but children and adolescents do not have the same safeguards to privacy of medical information in the school. Recording positive drug-test results on students' permanent educational records (under guidelines of the Family Educational Rights and Privacy Act), which are accessible to many school personnel, could have negative and long-term consequences. Strict attention to issues of confidentiality must be ensured.
It has not yet been established that drug testing does not cause harm. The following should be considered:
Students involved with illicit drugs may decrease their involvement in extracurricular activities to avoid drug testing. According to the National Institute on Out-of-School Time (www.niost.org), students who spend time in extracurricular activities are 49% less likely to use drugs. Without engagement in such activities, adolescents have a higher likelihood of dropping out of school, becoming pregnant, joining gangs, pursuing or increasing their use of drugs, and/or engaging in other risky behaviors.32–34
Positive drug-test results may cause increased family conflict rather than improve the home situation for the student.
Drug testing of adolescents is not performed for public safety. Even adults have mixed responses to the idea of widely applied drug testing. Although many support the idea of drug testing as a necessary measure for public safety from intoxicated or impaired pilots, bus drivers, police officers, and others, they often voice concerns when the application becomes more pervasive and random.
Dollars spent on drug testing may be more effectively spent on drug prevention programs or well-established counseling programs.
Drug testing youth who have not been implicated in using drugs may be perceived as being unfair and, thereby, may reduce trust and connectedness with their school, which are essential for maintaining lines of communication.2,33–35
DRUG EDUCATION AT SCHOOL
Schools may adopt a variety of alternatives to drug testing to address the issue of substance abuse, including offering after-school programs, incorporating life-skills training into drug education curricula, helping parents become better informed, providing counseling, identifying problem behaviors for early intervention, and promptly referring students to health care professionals for assessment and intervention. School-based health centers should have the capacity to counsel students who are in need of such treatment plans and connect students to available community resources.
Schools are appropriate settings for drug prevention programs for 3 reasons: (1) prevention must focus on children before their beliefs and expectations about substance abuse are established; (2) schools offer the most systematic way of reaching young people; and (3) schools can promote a broad spectrum of drug-related educational policies.36 Resources for the preparation of teachers, counselors, and other school personnel may be a valuable adjunct.19,20
Educators are challenged to make the facts about drug abuse meaningful to children and adolescents without enticing them to try drugs. There are many curricula designed for school use that have been proven to be effective and are delivered to students in ways that are interesting, interactive, and developmentally appropriate.36,38,39 Although many program approaches are available, some effective programs focus on enhancing students' problem-solving skills or aiding them to evaluate the influence of the media. Other effective programs help improve students' self-esteem, reduce stress and anxiety, or increase activities. These skills are taught by using a combination of methods including demonstration, practice, feedback, and praise.40
Another proven approach is “life-skills training,” designed to teach skills to confront a problem-specific focus, emphasizing the application of skills directly to the problem of substance abuse. One of the most studied programs is LifeSkills Training (National Health Promotion Associates, White Plains, NY), a universal school-based prevention approach (most often focused on 7th-graders) that teaches general personal and social skills training combined with drug-refusal skills and normative education. LifeSkills Training produces positive behavioral effects on alcohol, tobacco, and illicit drug use. This approach, with booster sessions that follow the initial program, is most effective.5 These effects continue years after the intervention.36,41,42 Many effective curricula and drug prevention programs use interactive materials and maximize group interactions with organized activities.36,38,39,43,44 Studies have demonstrated convincingly that the effects of school programs can be amplified substantially when community components are added.20
PARTNERSHIP BETWEEN SCHOOLS, MEDICAL HOME PROVIDERS, AND DRUG REHABILITATION PROGRAMS
Schools may partner with rehabilitation programs to provide care for a student to help successfully reintegrate him or her. Educational planning is an integral part of after-care contracts that pediatricians, mental health professionals, or rehabilitation programs form with students and their families. The school's roles in such a collaborative relationship include identifying any underlying learning disabilities that may have contributed to the problem, making special accommodations for students when necessary, providing remedial work so that students can catch up with their classmates, helping to reinforce expectations for students to attend school and to comply with follow-up or monitoring as prescribed by the health care professional or rehabilitation facility, and assisting with finding after-school programs. It is also important for students who have used substances to be assigned at least 1 trusted adult who is available in the school building to help them if they feel they need it. Those who are assigned to work with the student's drug problems must know how to respect confidentiality of treatment. This adult or another school health professional, school administrator, or designated staff member should be assigned to work with the student's pediatrician and rehabilitation personnel to communicate the student's progress or failure to progress.
The roles of pediatricians, mental health professionals, and rehabilitation programs in this collaborative relationship are to identify any mental health diagnoses and notify the schools of their relevance to the student's safety at school, to the student's educational program, and to school personnel or operations in general. Health care professionals also need to provide schools with treatment plans that may affect the school day while maintaining the student's confidentiality to the extent that is possible.
COMMUNITY COLLABORATION WITH SCHOOLS
Communities can send a clear and consistent message by developing and implementing a broad, comprehensive approach to dealing with substance abuse. Schools can serve as a focal point for such a community-wide effort. Community agencies can partner with schools to help monitor illicit drug use patterns in the local region to direct specific educational and preventive programs. Substance abuse problems that are associated with other mental health conditions can best be dealt with through comprehensive mental health programs that are capable of addressing prevention and intervention of both conditions. More information is available in the AAP policy statement on mental health in schools.45 School personnel should receive ongoing training, preferably by a health care professional who is skilled at the recognition of and risk factors for substance use and related disorders so that each staff member is able to guide faculty, parents, families, and others who are concerned about such use. As part of their community/school program to counter substance abuse, the community should provide regular activities that are supportive alternatives to the abuse of drugs.
RECOMMENDATIONS FOR PEDIATRICIANS
Pediatricians should not support drug testing in schools. If testing is performed at all, it should only be done as part of a funded, comprehensive approach to addressing substance abuse in the school and in the community. Examination of alternative approaches should be carefully evaluated for effectiveness and cost.
Because of ongoing concerns about the implications of school-based drug-screening programs, the AAP membership should support and promote alternative school-based efforts to combat substance abuse. In addition, pediatricians should:
Serve as a medical home and resource for patients and their families and offer primary (ie, universal approaches designed to target all patients or potential users before a problem occurs) and secondary (ie, approaches targeted at patients who have screened positive for high-risk behaviors such as tobacco, alcohol, or inhalant use) prevention of illicit drug use.
Identify patients with personal, medical, mental health, social, or academic problems who might be at high risk for drug abuse. Consider the use of screening tools and questionnaires, such as the Guidelines for Adolescent Preventive Services surveys (www.ama-assn.org/ama/pub/category/1980.html) and the CRAFFT tool,22 in the care of adolescent populations to identify patients who might need additional assessment and treatment. Mental health problems such as anxiety, depression, attention-deficit/hyperactivity disorder, and other diagnoses may coexist with substance abuse. The patient's progress should be monitored carefully so that ongoing assistance can be provided.
Support communication strategies that maintain patient/student confidentiality while coordinating treatment among the medical home provider, the family, and school-based programs.
Promote awareness of changing patterns of illicit drug use through local resources as well as through AAP chapter and district channels.
Raise awareness about mental health and rehabilitation services related to drug use that are available within the community to aid the student, family, and school.
Support and advise communities on the importance of clear and consistent community-wide messaging on illicit substance use and the promotion of activities that are free of drug and alcohol use.
Become familiar with the local school district's substance abuse prevention and health promotion programs.
COUNCIL ON SCHOOL HEALTH 2005–2006
Barbara Frankowski, MD, MPH, Chairperson
Rani Gereige, MD, MPH
Linda Grant, MD, MPH
Daniel Hyman, MD
Harold Magalnick, MD
*Cynthia J. Mears, DO
George Monteverdi, MD
Robert D. Murray, MD
Evan Pattishall, MD
Michelle Roland, MD
Thomas L. Young, MD
Howard Taras, MD
Spencer Su Li, MPA
COMMITTEE ON SUBSTANCE ABUSE 2005–2006
Alain Joffe, MD, MPH, Chairperson
Marylou Behnke, MD
*John R. Knight, MD
Patricia Kokotailo, MD, MPH
Tammy Harris Sims, MD, MS
Janet F. Williams, MD
Ed Jacobs, MD
Karen Smith, MS
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.