ART THERAPY: A COMPLEMENTARY APPROACH TO EXISTING SUBSTANCE ABUSE PREVENTION PROGRAMS

Thesis Presented to the Faculty of the Graduate School Medical College of Pennsylvania and Hahnemann University

In Partial Fulfillment of the Requirements for the Degree Master of Arts

by Susan E. Casper Creative Arts In Therapy May 1, 1996

ABSTRACT

This literature review addresses art therapy as a possible complementary approach to existing prevention and early intervention programs designed to eliminate or deter gateway drug use. It was the author's hypothesis that a

review of the literature would support the use of art therapy in prevention programming targeted towards latency aged children from urban environments. Available literature was reviewed in order to provide statistics and current incidence of marijuana, alcohol and nicotine use throughout the United States. The gateway drug

abuse theory, risk factors which cause children to be vulnerable to drug use, and characteristics of latency aged children and urban environments are explored in this literature review. Effective approaches to prevention

programming and issues in health care reform are addressed. Also included in the review of the literature are current parameters in art therapy in the treatment of chemical dependency. The discussion will involve practical

i i

approaches and art therapy techniques used by the author when working with children to prevent drug abuse in the urban community. It appears that art therapy could provide latency aged, urban children with an alternate means of communication, thereby enhancing existing methods, techniques and processes of early intervention programs targeting gateway drug abuse.

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DEDICATION

Mom and Dad,

Thank you for your support and love which You brought me life and I cherish these gifts

has cradled me over the years.

you've given me love and happiness.

and dedicate this thesis, a symbol of my appreciation and love, to you.

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ACKNOWLEDGMENTS

First and foremost I would like to thank Ron Hays for his support and guidance. His accommodating nature and

talent as a clinician has prompted the completion of this thesis. Ron, thank you for being a member of my committee Both have

and taking on the role as my supervisor.

contributed to my strength as an art therapist. I would like to acknowledge Dr. Marjorie Saul for years of guidance. It was her faith and belief in my talents that Dr. Saul, thank

lead me to apply to the Hahnemann program.

you for helping to shape my professional identity and for seeing me through the most difficult of times. A big thanks to Kathie Mendenhall for providing me with my first art therapy internship and supervision despite her hectic schedule. Kathie, thank you for being my mentor.

Thank you to Dr. John Lewis and Marsha McGlinchey for offering suggestions and helping to refine my thesis. Thank

you for being an intricate part of my thesis committee.

Last but certainly not least, mounds and heaps of love to Lori and Kitty. and safe place. Thank you for making home a nurturing

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Two Suffering Men

I sat across, behind my desk, and told him I thought he might be an alcoholic. I never been drunk," he said I made a note on the medical chart. I could see him getting irked. His liver sick, his wife gone with the kids! I made a note on the chart. I saw him gaining rage. He clenched his fists, leaned forward his arms on the desk. He held his breath until he turned red, then, sighing, fell back in his chair and cried. Breaking a long pause, he asked, "You're telling me I'm alcoholic? How in hell would you know, in your ^pretty' white picturebook middleclass hospital coat?" His face suddenly tensed. He pursed his lips and lifted himself from the chair. He stood tall, straight up, bulging with pride for all the ground in years of his laboring trade, shouting, "Stay out of my head. Stay OUT of my head!" and slammed the door behind him.

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I longed to lower my eyes and cry. But, from the bottom of the drawer of my desk, just one small glass of vodka and chlorophyl candy tastes so damn good in the morning. Eugene Hirsch from

Wedding, D. (1995). Behavior and Medicine. (Second Edition). St. Louis, MO: Mosby.

*Although this thesis proposes substance abuse prevention specifically for latency aged children from urban areassubstance abuse occurs among all races, ages, cultures, and socioeconomic classes. We must not be ignorant to this.

TABLE OF CONTENTS

ABSTRACT DEDICATION ACKNOWLEDGMENTS TABLE OF CONTENTS METHODOLOGY INTRODUCTION LITERATURE REVIEW Drug Abuse Statistics Gateway Drug Theory Risk Factors Effects of Gateway Drug Abuse Drug Wise Art Therapy Definition Developmental Stages in Children's Art Advantages Appropriate Art Media Learning Through Art Creative Arts Treating Addiction Art Therapy in the Public Urban School Early Intervention/Prevention Programming United States Health Care Reform Existing Prevention Programs
i x

11

ill

iv ix xi 1

8 14 21 28 33

35 37 40 43 45 53 58

61 64

Effective Strategies Planning a Program T a r g e t P o p u l a t i o n : Latency A g e d Y o u t h s In U r b a n Areas The U r b a n Community Social Support in t h e U r b a n C o m m u n i t y Social Impact of Urban Living Latency Aged Youths

66 76

78 84 86 88

DISCUSSION & CONCLUSIONS SUMMARY CONCLUSIONS REFERENCES

95 12 7 129

METHODOLOGY

Data was collected through MEDLINE, PsychLit, Cinahl, Wilson Social Science Index and ERIC databases. In

addition, the internet was searched for statistics regarding present day drug use. University libraries were searched

for recent publications pertaining to this literature review. The data was organized and synthesized to form a

review of the literature regarding the viability of art therapy as a complementary approach to the early intervention of gateway drug abuse among latency age urban youths.

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INTRODUCTION

The purpose of this thesis is to propose art therapy as a possible complementary approach to existing substance abuse prevention programs. Art therapy, when coupled with

drug abuse prevention programs, can possibly enhance a program's effectiveness. As a result of this marriage,

goals to prevent chemical dependency and delay or impede initial drug experimentation may be achieved with greater success. Why wait until a child is suffering from drug Interventions can successfully stop

addiction to intervene?

drug use before abuse or addiction occurs (Benard, 1993). To be chemically dependent is to build walls around yourself, high, thick, impassable walls which keep your feelings trapped inside. To be chemically dependent is

to live in self-imposed isolation. It is to feel unwanted, uncared for, and unappreciated. It is to It is

live on the fringes, and never fit in anywhere.

to feel a terrible loneliness in the pit of your being that no amount of alcohol or other drugs can ever appease. ("How It Feels To Be Chemically Dependent,"

Evelyn Leite, Johnson Institute, Inc., Copyright 1987. Edited by Pamela Espeland) That moving passage

describes a terrible existence, one that we do not want for our young people. (Monye & Oyemade, 1990, p. 19). There has been a dramatic increase in the prevalence of drug abuse during the last 30 years. Although the use of

illicit drugs in this country follows a cyclic pattern, it reached an all time peak during the late 1970's and early 1980's. Estimates indicate that early in the 1960's less

than 5% of the population of this country had ever tried an illicit drug. By the early 1970's, evidence suggested that

10% of all Americans, primarily those less than 25 years of age, had used such drugs (Goplerud, 1991). In 1982 an

estimated 66% of American youth had used an illicit drug before they graduated from high school (Winger, 1992). Although the 1993 National Household Survey on Drug Abuse concluded that measures of illicit drug use indicated a downward trend between 1979 and 1990, the 1993 National Household Survey on Drug Abuse suggests that "significant declines in the prevalence of illicit drug use did not occur in 1993. It is not known whether the 1993 data reflects a

temporary interruption of the substance abuse trend, a

leveling off of prevalence, or the start of an upturn in drug use" (National Household Survey, 1993). Whether this

data reflects a deceleration in substance abuse or the start of an upturn in drug use, "youths raised in impoverished urban communities will still continue to be at high risk for involvement in drug use" {Greenwood, 1992, p. 444) Substance abuse occurring in metropolitan areas is a serious problem which needs to be addressed. "In 1993, the

rate of illicit drug abuse was 5.6% in large metropolitan areas and 6.4% in small metropolitan areas compared to 4.6% in non metropolitan areas" 1993) . Higher rates of drug use in metropolitan areas may result in high risk behavior among city youths. Behaviors (National Household Survey,

such as promiscuity (Clapper & Lipsitt, 1991; Cox, D'Angelo, & Silber, 1992), drug trafficking (Black, Feigelman, Li, & Stanton, 1994), delinquency, crime, violence, including homicide, and truancy from school (Arkin & Funkhouser, 1990; Danish, Farrell, & Howard, 19 92,- Goplerud, 1991; Johnson, 1990) are prominent in urban environments. In turn, these

behaviors may result in imprisonment (Schubiner, 1993), low socioeconomic status (Johnson, 1990; Sabol, 1991) and a

breakdown of interpersonal and intrapersonal relationships. Moreover, substance abuse may lead to psychological and physiological illness, as well as influence the overall decline of urban communities (Johnson, 1990}. Yet, despite

these adverse effects, drug abuse among urban youth shows little sign of abating (Greenwood, 1992). Perhaps, this is

due to high levels of drug availability and neighborhood dealing (Black, Feigelman, Li, & Stanton, 1994) or the chronic stressors of urban life. Stressors such as poverty,

violence, inadequate housing, crime, racial discrimination of minority groups and broken families are commonplace in

the inner city (Albrecht & Rosella, 1993) and drug use may provide a temporary escape from them (Brown, 1990) . In addition, living in an economically depressed environment with high unemployment rates as well as inadequate health and social services may also continue the urban substance abuse epidemic (Arkin & Funkhouser, 1990) . Low education levels within urban communities and low achievement expectations from society are other factors that may foster the continuance of the inner city substance abuse epidemic (Arkin & Funkhouser, 1990).

Investigation on how to deter illicit substance abuse in metropolitan areas is much needed. A possible solution

to this problem may be to begin by guiding urban youths towards early intervention of gateway drugs--alcohol, nicotine and marijuana. This technique is termed

"preventive" and is defined by its primary emphasis on promoting health and preventing disease in both individuals and populations (Black, Feigelman, Li, & Stanton, 1995) . Art therapy as a preventive tool may increase the probability of controlling the substance abuse epidemic in urban areas. David Read Johnson, PhD, RDT, Editor-in-Chief

of The Arts in Psychotherapy, Volume 17 states "successful art therapy treatments for substance abuse will be tied closely to prevention models" (Johnson, 1990, p. 295). Examination of art therapy as a complementary approach utilized in early intervention programs is needed. the capacity to stimulate learning. Art has

Man learns through Art

seeing, hearing, feeling, smelling and tasting. stimulates these senses.

"The greater the opportunity to

develop an increased sensitivity and the greater the awareness of all the senses, the greater will be the opportunity for learning" (Brittain & Lowenfeld, 1987, p.

11).

For children, art functions as a natural language (Brittain & Lowenfeld, 1987). It is a communication system

in which visual statements clarify ideas and stimulate further ones. It is the objective of the author to examine

art therapy as a complimenting approach to existing practices utilized to deter substance abuse in urban children. I will focus on the power of art therapy to

increase the effectiveness of a substance abuse prevention program. A review of the literature will be presented inspecting art therapy, latency age urban youth, early intervention methodology, and gateway drugs, i.e., alcohol, nicotine, marijuana. The researcher was unable to find any published

study that quantitatively attempts to prove art therapy's effectiveness in enhancing substance abuse prevention programs. thesis. While many treatment professionals support the use of art therapy as part of an overall treatment strategy, its value in supplementing drug abuse prevention programs remains unsubstantiated. This review of the literature is a This gap in knowledge supports the need for this

preliminary effort toward validating art therapy to be effective when coupled with existing substance abuse programs. It is the goal of the author to provide

synthesized knowledge which may serve as a basis for later studies regarding art therapy as a tool for specifically, the early intervention of gateway drug abuse among latency age youth residing in metropolitan areas. In the conclusion

and discussion section of this thesis, vignettes are provided which correlate with prior work experience in which art therapy was used to complement a substance abuse prevention program.

LITERATURE REVIEW Drug Abuse

Statistics. Drug abuse is the use of a mind altering substance in a way that differs from generally approved medical or social practices. Written in another way, when the

continued use of a mind altering substance means more to the user than the problems caused by such use, the person can be said to be abusing the drug (Schuckit, 1989, p. 4 ) . The 1993 National Survey on Drug Abuse cites, an estimated 103 million persons age 12 and over had used alcohol in the past month, which was approximately 50 percent of this total population. Americans were heavy drinkers. About 11 million

These heavy drinkers were Of the 11 million

more likely to be illicit drug users.

heavy drinkers, 3 million or 25.5 percent were current illicit drug users. Among the 92 million current drinkers

who were not heavy drinkers, the rate of illicit drug use

was 7.6 percent.

Pertaining to alcohol prevalence in

geographic areas, since 1985, the rate dropped significantly in large metropolitan areas from 65 percent in 1985 to 52 percent in 1993 and in small metropolitan areas from 56 percent to 48 percent. Yet, in non metropolitan areas the Heavy alcohol use has dropped

rate has remained the same.

significantly in large metropolitan areas {6.7 percent in 1985 and 4.1 percent in 1993) but changed little in non metropolitan regions. The National Household Survey on Drug Abuse continues citing, an estimated 50 million Americans were smokers in 1993. This represents a smoking rate of 24 percent for the

population of twelve years and older. Current cigarette smoking has declined from 26 to 24 percent between 1992 and 1993. In 1985, 31 percent of the population or 60 millions Current smokers are more Among

Americans, had been smokers.

likely to be heavy drinkers and illicit drug users.

smokers the rate of heavy alcohol use (five or more drinks on five or more days in the past month) was 11.1 percent, and the rate of current illicit drug use was 12.3 percent. Among nonsmokers, only 3.4 were heavy drinkers and 3.5 percent were illicit drug users. Geographically, the rate

'

of smoking was 22 percent in large metropolitan areas, 25 percent in small metropolitan areas and 28 percent in non metropolitan. The National Household Survey on Drug Abuse also states in 1993, an estimated 9 million Americans were current marijuana or hashish users. This represents 4.3 percent of Marijuana is by far the

the population aged 12 and older.

most prevalent drug used by illicit drug users, as about three quarters {77 percent) of current {past month) illicit drug users were marijuana or hashish users in 1993. The

number of marijuana or hashish users did not change between 1992 and 1993 {9 million in both years). However, use did

decline significantly since 1985, when there were 17.8 million users. The rate of use declined from 9.3 percent in Frequent use of marijuana, defined as

1985 to 4.3 in 1993.

use on a weekly basis during the past year, remained unchanged from 1991 through 1993 at about 5.1 million weekly users (2.4 percent of the population in 1993) but was significantly lower than in 1985, when there were an estimated 8.9 million weekly users (4.6 percent of the population). Incidentally, the rate of marijuana use for 12

to 17 year olds was 4.0 percent in 1992 and 4.9 percent in

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1993.

While this is not a statistically significant change,

it is still noteworthy given the recently reported increase in marijuana prevalence among high school students. The

NHSDA did find a significant increase in past year marijuana use among youths (8.1 percent in 1992 and 10.1 percent in 1993). Pertaining to geographical locations, since 1985,

the rate of marijuana and hashish use has dropped significantly in large metropolitan areas (from 13.6 percent in 1985 to 5.6 percent in 1993), in small metropolitan areas (11.8 percent to 6.4 percent) and in non metropolitan areas (7.5 percent to 4.6 percent. Overall, The 1993 National Household Survey of Drug Abuse rates current and heavy alcohol use in the U.S. as having changed little in the past several years, and there are signs that alcohol use may be increasing among youths. In addition, among youths ages 12 to 17 years in the NHSDA the rate of cigarette use was 9.6 percent in both 1992 and 1993. Significant increases in smoking rates were found Marijuana use is also

among students between 1992 and 1993.

prevalent among youths (4.0 percent in 1992 and 4.9 percent in 1993), but statistical evaluation of this change indicates it would be significant only at the p = .126

1 1

level.

Thus, the NHSDA data does not (permit us to)

conclude that marijuana use has increased among youth, although use is prevalent. The Indiana Prevention Resource Center (1995), author of Monitoring the Future Study--National High School Drug Use Study, claims drug use rises again in 1995 among American teens. The proportion of eighth-graders taking any

illicit drug in the twelve months prior to the survey has almost doubled since 1991 (from 11 percent to 21 percent). Since 1992 the proportion using any illicit drugs in the prior twelve months has risen by nearly two-thirds among tenth-graders {from 20 percent to 33 percent) and by nearly half among twelfth-graders (from 27 percent to 39 percent). In 1995, marijuana use in particular, continued the strong resurgence that began in the early 1990's, with increased use at all three grade levels. Among eighth-graders, annual

prevalence has risen to two-and-one-half times its level in 1991, from 6 percent in 1991 to 16 percent in 1995. Among

tenth-graders, annual prevalence has nearly doubled from the low point in use in 1992 of 15 percent to 29 percent in 1995; among twelfth-graders annual prevalence has increased by more than half, from the low point of 22 percent in 1992

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to 35 percent in 1995.

Nearly one in twenty of today's high

school seniors is a current daily marijuana user, and roughly one in every thirty five tenth-graders. Fewer than

one in a hundred eighth-graders use at that level. Alcohol use among American secondary students generally has remained fairly stable in the past few years, though at rates which most adults would consider to be unacceptably high. In 1995 the proportions of students having five or

more drinks in a row during the two weeks proceeding the survey were 15 percent, 24 percent, and 3 0 percent for eighth-, tenth-, and twelfth-graders, respectively. Cigarette smoking rose again in 1995 among American youth. This is the fourth year in a row of increase for

eighth- and tenth-graders, and the third year in a row for high school seniors. Among eighth- and tenth-graders, the

proportion who reported smoking in the thirty days prior to the survey has increased by one-third since 1991. Some 19

percent of the eighth-graders and 28 percent of the tenthgraders now report such use. Since 1992, the smoking rate

has risen by more than one-fifth among high school seniors, with one in three (34 percent) now saying they smoked in the thirty days prior to the survey.

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Gateway Drug Theory. One of the most influential attempts to describe the patterns of substance abuse is the concept of stages. Chen,

Kandel, and Yamaguchi (1992) posits there is a developmental process in which youths become initiated into substance abuse through a sequence of stages with each prior drug stage acting as a potential gateway to the former stage. It

is proposed that youth progress from legal to illegal and to less to more serious drugs. The stages begin with the legal

drugs and include: (a) no use of any drug, (b) use of alcohol and (c) use of cigarettes and hard liquor. At this

point, the use of illegal drugs begins with (d) marijuana and progresses to (e) other illicit drugs such as cocaine, heroine and opiates. According to Chen, Kandel, and

Yamaguchi (1992), drugs begun in earlier stages are "carried over" and continued in the next stage as new drugs are added to the substance abusers repertoire (Bailey, 1989) . This pattern has been observed not only in the United states but also in France and Israel by Adler and Kandel in 1981. In

addition, Donovon and Jessor have suggested problem drinking be a stage designated between the use of marijuana and other

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illicit drugs (Chen, Kandel, & Yamaguchi, 1992, p. 447). The identification of these stages has had widespread policy implications. It has lead to the labeling of alcohol

and cigarettes as the "gateway drugs" and to the initiation by the government of prevention and intervention efforts designed to hinder involvement in these drugs (Chen, Kandel, & Yamaguchi, 1992, p. 447). Bailey (1989) defines gateway drugs as the first drugs used. Thus, he categorizes alcohol Bailey

and tobacco products as the primary gateway drugs.

(1989) continues citing via Voss and Clayton, "Data show that cigarette and alcohol use relate strongly to use of illicit drugs such as marijuana and cocaine" (p. 152). Although early pioneers categorized alcohol and cigarettes as the gateway drugs this classification has changed due to the passage of time. In the 1992, Bell,

Ellickson, and Hays traced the sequence of drug use over time. In this Longitudinal Scalogram Analysis marijuana was

added as a component to gateway drugs. On the basis of these studies, prevention experts have stressed the importance of delaying or preventing initiation of the gateway drugs-alcohol, cigarettes and marijuana-both as a goal that is important in its own

15

right and as a potential strategy for preventing use of harder drugs (Bell, Ellickson, & Hays, 1992, p. 441). Research indicated legal drug use precedes use of most harder drugs. The sequence that best fits the data includes

separate stages for both regular drinking and regular smoking. Consistent with Donovon and Jessor, this study

found regular alcohol use as a step in the drug involvement scale. Bell, Ellickson, and Hays (1992) found, as did

Donavon and Jessor, increased involvement with alcohol followed cannabis initiation and preceded experimentation with harder drugs for all races studied excluding Asians. This studied provided evidence that regular smoking constitutes a separate stage of drug involvement that precedes the onset of hard drug use. Although this evidence For

was supported by only non-Hispanic white youth.

minority populations such as, Blacks, Asians and Hispanics, regular smoking accompanied or followed to hard drug use. This study also suggested, as did Mills and Noye's (1984) contention to continue using gateway drugs even after experiences with harder drugs have occurred (Bell, Ellickson, & Hays, 1992). This suggests youth does not Instead

replace initial drugs of choice with harder drugs.

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the new, harder drug is added to their repertoire while deepening the involvement with gateway drugs. It is

concluded, increased levels of drinking provide a useful indicator of the risk of using harder drugs for all ethnic groups studied excluding Asians. Pertaining to this sample,

by the eighth grade 90 percent of youths had tried alcohol. At this age or in the near future, if a youth is drinking

an average of two drinks per week this reveals the individual will most likely be experimenting with harder drugs. For all ethnic groups, excluding Whites, regular

weekly smoking supports hard drugs are in the process of being used or have previously been used. Overall, this

study emphasizes the importance of prevention efforts aimed at curbing the transition to regular use of alcohol and cigarettes as well as there initial use. Bell, Ellickson,

and Hays (1992) conclude involvement with legal drugs puts youths at risk for future involvement with hard drugs and the often the exasperation of gateway drug use. In 1992, Chen, Kandel, and Yamaguchi, conducted a study which provided further evidence for the gateway theory. "Sequential stages of involvement in alcohol and/or cigarettes, marijuana and other illicit were studied on a

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longitudinal basis" (Chen, Kandel, & Yamaguchi, 1992, p. 447). In this study, former hypotheses were modified. Three deviant patterns of progression involve modifications in the role of licit drug progression. These modifications are: (a) use of cigarettes do not have to precede the use of other illicit drugs, (b) if the use of cigarettes precede the use of marijuana, the use of alcohol does not have to precede the use of marijuana and (c) the use of alcohol and either cigarettes or marijuana, but not both, may precede the use of illicit prescribed psychoactive drugs (Chen, Kandel, & Yamaguchi, 1992, p. 450). These modifications added to Kandel's original model suggests evidence pertaining to an individual's drug history is especially important when assessing if an individual may move towards the progression of hard drug use (Chen, Kandel, & Yamaguchi, 1992). Age of initiation into the use of a

drug class and the extent in which the drug is utilized is equally important. Therefore, knowing this vital

information pertaining to the sequential patterns of drug involvement can help determine youths future involvement in drugs.

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Although, the "gateway" hypothesis--a theory arguing that initiating lower order substances, such as alcohol, is a necessary but insufficient condition for using higher order substances, or hard drugs-is a common explanation for the stage-like progression of substance use there exists alternate explanations. Todd Q. Miller (1994) researched The first is the statistical

two alternate explanations. independence hypothesis.

This involves the differences in

the prevalence rates (availability) and age of onset of different substances which may account for the stage-like phenomena. study. Kandel supported this hypothesis in her 1992 "gateway theory".

Yet, married it to her original

Miller offers this theory as independent and refers to it as the statistical independence hypothesis (Chen, Kandel, & Yamaguchi, 1992). It suggests the use of one substance not

to be correlated with or predicative to the use of another substance. In other words, the use of substances rely The second alternate This

primarily on independent variables.

explanation is the problem behavior hypothesis.

hypothesis states some youths develop a problem orientation which predisposes them to experience with drugs. Miller

tested not only this problem behavior theory but also the

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gateway theory and the statistical independence hypothesis. Results showed a stage-like pattern of substance use that was in large part produced by statistically independent processes (Chen, Kandel, & Yamaguchi, 1992). These

statistically independent processes may have occurred from differences in age of onset or availability of various substances. Pertaining to the gateway theory, Miller does

not discount it but rather states researchers must examine the transitions between each stage (Chen, Kandel, & Yamaguchi, 1992} . Certainly it is important to be knowledgeable about the stage-like progression of substance abuse. "To develop

effective guidelines for preventing or reducing drug use, one needs to understand how people become involved with drugs and research on the stages of drug use has played an important role in this endeavor" (Bell, Ellickson, & Hays, 1992, p. 441). Still, one may wonder what makes drug use so appealing. Why do young people become drawn into this What Social, Personal What

stage-like progression of drug use?

and Environmental factors place urban youth at risk?

factors put urban, latency aged youths at high risk for involvement with marijuana, cigarettes and alcohol?

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Risk Factors. Webb (1991) studied risk factors and their relation to initial alcohol use among early adolescents. supported, risk factors are shown to be linearly related to frequency of drug use as well as the extent of drug use. Deviant behavior, tolerance for deviance, Data

sensation seeking, peer use of alcohol, parental and peer approval of alcohol use, grade average and relationship with father were found to be the strongest risk factors in this study of twelve year olds. These

factors were said to have lead to the initiation of substance use (Baer, Caid, McKelvey, Mclaughlin, & Webb 1991 p. 563). In addition, Webb's {1991) study also strongly suggests family problems precede initiation of alcohol use. The U.S.

Department of Health and Human Services agrees and reports numerous risk factors which may contribute to the use of drugs by urban youth. Many are correlated to the

dysfunctional family, dysfunctional parenting styles and parental dysfunction (Monye & Oyemade, 1990). "Increased

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alcoholism, drug abuse and nicotine dependency in parents, as well as, increased antisocial or sexually deviant behavior may predispose a child as vulnerable to chemical dependency" (Arkin & Funkhouser, 1990, p. 22). Parental

absenteeism, family lines of mental illness, family conflict, physical, emotional and sexual abuse, decreased family rituals and organization, lack of family cohesiveness and social isolation are also listed as risk factors (Monye & Oyemade, 1990). Dembo (1992) finds, " y u t n ' s family

background and problem factors, their sexual victimization and physical abuse experiences have been positively correlated to their drug and alcohol use and delinquent behavior over time" (Brown, Dembo, Schmeidler, Williams, & Wothke, 1992, p. 261}. In addition, parents who lack the

knowledge of effective disciplining and management skills may have difficulties structuring a family atmosphere which will be drug free (Arkin & Funkhouser, 1990; Monye & Oyemade, 1990) . Moreover, The Office of Substance Abuse Prevention, as well as, Vailiant and Milofsky claim, individuals with poor support systems and decreased social networks may be prone to abusing gateway drugs (Monye & Oyemade, 1990). Parental unemployment, low levels of

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parental education and large overcrowded families contribute to a child's potential risk (Greenwood, 1992; Monye & Oyemade, 1990). Living in an economically depressed area,

such as many urban communities also increases a child's potential to abuse drugs Goplerud, 1991}. (Arkin & Funkhouser, 1990;

This will be further discussed in section

II of the literature review. A physiological component may increase the chances of a child's involvement with drugs, as well as, earlier behavioral problems. Early aggressiveness, social

inhibition, hypersensitivity, hyperactivity, poor coping skills, low self esteem, difficulties in relationships and impulsiveness all contribute to the potential of future drug abuse (Greenwood, 1992; Monye & Oyemade, 1990,- Sabol, 1991). Children prone to delinquent acts and violence also tend to abuse gateway drugs prior to adolescence (Arkin &. Funkhouser, 1990). Donovon, Jessor and Farrell agree,

"measures of the frequency of cigarette use, alcohol use, marijuana use, delinquency, and sexual intercourse were positively correlated with, each other and negatively correlated with measures of conventional behavior, including

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school attendance and grade point average" (Danish, Farrell, SL Howard, 1992, p. 709) . Early antisocial behaviors have consistently been found to be associated with increased delinquency and drug abuse. Consistently, all recent epidemiological

studies cite the best predictors of future drug use are prior use, the presence of other problem behaviors, and association with delinquent peers (Greenwood, 1992, p. 447) . Greenwood continues stating, other predictors include: parental and sibling drug use or criminal behavior (Kandel et al. 1978; Loeber and Dishion 1983; McCord 1979; Robins 1979; West and Farrington 1973); poor and inconsistent family management practices (Loeber and Dishion 1983; McCord 1979; Simcha-Fagan and Gersten 1986); low commitment to education (Elliott and Voss 1974; Friedman 1983; Hirschi 1969; Kandel 1982); neighborhood factors such as high density, high crime rate and rapid change
{Kobrin and Schuerman 1 9 8 1 ) ; alienation from dominant

values of society (Jessor and Jessor 1978; Kandel 1982); low religiosity (Jessor, Chase, Donovon 1980;

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Kandel 1982); personal attitudes and beliefs such as perceived use of substances by others (Jessor and Jessor 1978; Kandel et al. 1978); Robins and Ratcliff 1979) {Greenwood, 1992, p. 448). In addition, preadolescents believing alcohol or marijuana to be the most dangerous drug used these substances less often than those believing LSD, cocaine, or PCP to be the most dangerous. This study collaborates the notion that

beliefs about the dangers and health risks of specific substances correspond to lower usage rates for the specific drugs (Berdiansky, 1991). Yet, youngsters, who despite

being educated on the health hazards and dangers of gateway drugs, continue to use marijuana, alcohol and nicotine. Despite the short-term "high" these drugs produce, other reasons exist as to the reason children become involved in the stage-like progression of gateway drug abuse. In October of 1992, Peter Greenwood indicated a variety of theories to explain why people use and/or abuse alcohol and drugs. "At the simplest level of causation, substance

abuse has been attributed to the individual's desire to get 'high', deaden emotional and physical pain, escape reality, relax, improve creativity or sensual pleasure, decrease

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social pressure or to fulfill an addiction" (p. 448). In general, most experimentation takes place in a social setting and is best explained by social learning or social influences models. However, escalation to regular use or

abuse appears better explained by psychological or biosocial theories of addiction or coping with stress (Greenwood, 1992). Vaughan and Wills (1989) studied the mechanisms of They concluded, adolescents

support and substance abuse.

with a strong peer orientation may be exposed to more situations where substance abuse is occurring, may be more likely to model their behavior on that of their peers, or may be more susceptible to explicit social pressure to use drugs. In addition, adult support makes adolescents less Yet, having

susceptible to modeling the behavior of peers.

parents who smoke or drink strengthens the effect of substance use behavior by peers (Vaughan & Wills, 1989) . Overall, the data suggests modeling as a plausible cause for the use/abuse of gateway drugs. Adler, Irwin, Kegeles, Millstein, Tschann, and Turner (1994) also studied the initiation of substance abuse in early adolescence. The researchers found support for their They claim, among young

early maturation hypothesis.

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adolescents, early maturers of both sexes report more substance use within the following year, compared with those later maturing adolescents. Adolescents experiencing more

emotional distress at first assessment also engage in more substance use within the next year, compared with those with lower levels of distress. However emotional distress does

not mediate the relationship between pubertal timing and substance abuse; that is, emotional stress is not related to pubertal timing but contributes to independently to subsequent substance use. Early substance use among early

maturing girls may stem from social processes such as being perceived as older and more mature than other, same-age girls, socializing with older peers, and {as a result) having greater opportunity and perhaps pressure to engage in substance use. It seems early maturing boys may be

experiencing similar social processes to that of the girls, thus having greater opportunity and pressure to experiment with alcohol and drugs {Adler, Irwin, Kegeles, Millstein, Tschann, & Turner, 1994}. The reasons youth become involved in gateway drug abuse and the factors which put them at risk initially overlap and ideally should be woven into the same web. These factors

27

spring from common etiological sources in which the presence of maladaptive behaviors, including substance abuse, and risk factors are interwoven (Greenwood, 1992) .

Effects of Gateway Drug Abuse. Risk factors are also closely correlated to the effects of substance abuse. If gateway drug use continues, children

may become victims of the factors that placed them at risk initially. They may become the alcoholic parent or high Chen, Kandel, and Yamaguchi (1992)

school drop out.

reported that for both men and women, adolescent drug use is correlated to later unemployment and/or job instability. "Newcomb and Bentler reported finding that the 'consequences' of adolescent drug use included job stability and the 'forsaking of educational pursuits'" (Chen, Kandel, & Yamaguchi, 1992, p. 441). Friedman agrees, in his 1993 study, regarding early teenage substance abuse as a predictor of educational-vocational failure. Drug abuse can result in physiological illness also and young people need to learn that alcohol and other drugs can harm the body. Even youngsters who are still thinking in First,

concrete terms can understand two critical concepts.

28

the smaller or younger the individual who is using drugs, the more damage it will do to the body. When children and

teenagers drink, because they are younger and smaller physically and their body, metabolism, brain and sexual systems are still being developed, these systems will be effected much more, and more quickly, than that of an adult. Second, the more drugs and alcohol consumed the more damage it does to the body. Moreover, educating the children on

both long and short term effects of gateway drug abuse is also extremely important when attempting to delay or prevent use (U.S. Department of Education, 1992). Pan American Health Organization {1990} states the immediate or short term effects of smoking can effect the respiratory system. Smoke immediately stops the "mucus As a result,

escalator" for approximately twenty minutes.

mucus gets trapped in the lungs and eventually a "smokers cough" develops. This cough is the body's way of trying to In addition, bad breath is The tar contained

get the esculator working again.

developed from smoking and yellow teeth.

in cigarettes contains poisons such as in bug sprays and the black top of a driveway. People who continue smoking for a

long period of time become susceptible to diseases such as,

29

emphysema, asthma, cancer, coronary artery, and disease/hypertension. Also, pregnant women who smoke can

give their children fetal alcohol syndrome. Like smokers, people who drink alcohol for extended periods of time become susceptible to developing different diseases or syndromes. Some of these are, cirrhosis of the An

liver, brain cell death, hypertension and ulcers.

individuals immune system can become damaged which may deplete the bodies vitamins and minerals essential for growth and decrease the bodies ability to fight off disease. Frequently, long term alcohol abuse effects the users behavior which in turn effects the family of the user. Abuse, unemployment, hopelessness and inability to function in society may occur. For men who are chronic drinkers,

reduced levels of testosterone and increased levels of estrogen may lead to reduced sex drive, lower sperm count, sperm abnormalities, feminine pubic hair distribution, infertility, impotence and the development of other feminine features such as breasts. For females, a change in hormone

levels causes the loss of secondary sexual characteristics such as heavy fat deposits in the breasts and hips, reduction of regular menses, production of fewer ova and

30

infertility. functioning.

Alcohol will also alter the minds patterns of A very small amount of alcohol can effect a

young persons reaction time which may lead to accidents, whether they be on foot or in the car. A loss of memory may

occur as well as a failure to develop analytical skills. Alcohol damages the cells that line the digestive system. This causes many digestive problems such as bleeding, inflammation of the enzyme-making organs, and undigested food passing through the system. occur. Changes in behavior also

People can have mood swings when they drink alcohol.

Alcohol is a depressant, and it depresses the drinker who may become violent or suicidal (Boren & Spencer, 1990) . Alcohol also causes a lack of inhibition. This may lead to

high risk behavior such as unprotected intercourse while drinking. Clapper and Lipsitt {1991) conducted a study of risktaking and alcohol mediated unprotected intercourse. Results showed youngsters may engage in riskier sexual behavior when using alcohol. Monye and Oyemade of the U.S.

Department of Health and Human Services (1990) conclude children using alcohol or other drugs are at risk for contracting the HIV virus for several reasons. First,

31

decision making and risk perception will be impaired. Second, the bodies immune system will be compromised due to the consumption of alcohol which in turn will leave the body in a weakened state, more susceptible and vulnerable to contracting HIV. Lastly, alcohol, being a gateway drug, has

the potential to lead to the use of IV drugs which may leave children at high risk for contracting HIV through contaminated injection equipment. Like alcohol, marijuana has a physiological effect on the body both short and long term (Winger, 1992) . Smoking a joint cause the drug to reach the brain in ten seconds. Smoking marijuana, a.k.a., cannabis, pot, chronic, bud,

ganjah, dank, herb, buddha, reefer, mary jane, sinsemilla, grass, hash, dope, weed, causes damaged brain cells (U.S. Department of Education, 1992). Memory and coordination

skills become poorer and poorer and sexual dysfunction may occur. Ovaries and testes may loose their function and Youngsters need to be knowledgeable

infertility may occur.

that prolonged use of marijuana is just as deadly as the use of cocaine and crack. Commonly, long term use leads to Using may cause impairment of

psychological dependence.

short-term memory and comprehension, an altered sense of

32

time, inability to perform tasks needing coordination and concentration, such as driving a car. Motivation and

cognition may be altered making the acquisition of new information difficult. psychosis is possible. A paranoid experience is common and Because users often inhale the

unfiltered smoke deeply and hold it in their lungs as long as possible, marijuana is damaging to the lungs and pulmonary system. Marijuana smoke causes more cancer

causing agents than tobacco smoke (Pan American Health Organization, 1990).

Drug Wise. The U.S. Department of Health and Human Services (1993) states parents and teachers should be fully informed about drugs and the effects which may show in a child's appearance. After smoking marijuana a child may have red, The child may have taken It can be eaten

glassy eyes or be wzoning out".

marijuana in a variety of different forms.

like dried parsley, cooked in food, i.e., brownies and eaten, rolled into cigarettes then smoked, and packed in a pipe then smoked. When an individual smokes marijuana in When

cigarette form it is called, "smoking a joint".

33

marijuana is rolled into a cigar and smoked, it is referred to as, "smoking a blunt". listen for these phrases. Parents and Teachers need to Also, marijuana is often smoked Marijuana can

out of a long vertical tube called a "bong".

be in the form of soft gelatin capsules and taken orally. This is called Tetrahydrocannabinol, a.k.a., THC. It can be

smoked or eaten in the form of brown or black waxy cakes/balls. This form is called Hashish, a.k.a., Hash.

Concentrated syrupy liquid varying in color from clear to black is Hash Oil and when mixed with tobacco, it can be smoked. Parents and teachers should be drug wise and have

the knowledge needed to be aware and intervene if a child has been suspected of doing drugs or talking about trying them (U.S. Department of Education, 1992).

34

Art Therapy Art therapy has been successfully adapted to treat chemical dependency (Johnson, 1990; Julliard, 1994). Johnson (1990) writes, in the future, successful art therapy treatments will be tied closely to prevention models.

Defined. There are two ways in which art can be used therapeutically. The first is termed, art as therapy and

the later, art in therapy or art psychotherapy. Art as therapy focuses primarily on art expression for academic and aesthetic purposes. This approach, advocated rather than art

by Kramer (1958) emphasizes the art product as a springboard for psychotherapy.

"This approach implies

that producing artwork is an end in itself--that the creative process can be a means both of reconciling emotional conflicts and of fostering self-awareness and personal growth" (Bush, 1995, p. 2). Art as therapy is

35

conceived of primarily a means of supporting the ego, fostering the development of a sense of identity, and promoting maturation in general (Kramer, 1958), Unlike the

art in therapy/art psychotherapy approach, art as therapy does not depend on the uncovering of unconscious material or interpretation of unconscious meaning. The art in therapy/art psychotherapy approach is an insight oriented strategy. "Art is used as a vehicle for

communication for the purpose of developing insight and for resolving emotional conflicts--the art is used to symbolically understand what is happening within an individual" (Bush, 1995, p.2). In this approach the art therapist is primarily concerned with an individual's inner conflicts and helping to resolve them. "Process, form,

content, and verbal associations become important for what each reflects about personality development, personality traits, and unconscious" (Bush, 1995, p. 2) . Naumburg (1966) advocates this process oriented approach. The techniques of art therapy are based on the knowledge that every individual, whether trained or untrained in art, has a latent capacity to project his inner conflicts into visual form. As patient's picture

36

such inner experiences, verbally articulate.

they frequently become more

Through the use of graphic or

plastic expression, those who originally blocked in speech often begin to verbalize in order to explain their art productions (p. 1).
i

Developmental Stages in Children's Art. Before an art therapist chooses an orientation to practice, he/she must be knowledgeable regarding the developmental stages children proceed through in drawing. The normal sequence of development of art by children has been observed, and categorized since the 19th century by specialists in child development, psychology, and art education. Many different attempts

to describe art development make it clear that there is a generally predictable sequence of events for what most children will do in art as they mature. This

sequence has a kind of cyclic rhythm - moving forward and backward, expanding and contracting, with a pervasive thrust over time (Wadeson, 1980, p. 36) . While a child grows and continues experimenting with the art process, he/she will proceed through developmental

37

stages (Brittain & Lowenfeld, 1987}.

At the age of seven, a

developmentally "normal" child will be progressing through the period V. Lowenfeld {1987} termed and described as, The Schematic Stage. Children will have created a schema for

people and familiar objects indicated by geometric forms. This schema is a mental representation of the symbol repeated again and again by the child. It is only altered The

when a special meaning is to be conveyed by the child.

art product is an indication of the way a child comprehends and interprets space and objects. Drawings produced during

The Schematic Stage {seven to nine years} have the following characteristics: (a) recognizable human figures, (b) easily recognized views, i.e., side or front orientations, {c) primitive symmetry, {d) ordered space, (e) a flexible and static baseline, (f) multiple perspectives and (g) x-ray pictures. Drawings will be flat and lacking perspective.

Images should reflect knowledge of the child's environment and contain little if no overlapping of shapes and objects. Exaggerations, omissions or a change in a child's schema shows the effect of an experience while proportions depend on the emotional values a child attaches to the object or person rendered.

38

Between ages nine to twelve, a developmentally normal child will enter the period Lowenfeld (1987) termed and described as, The Gang Stage. "It is at this time children

lay the ground work for the ability to work in groups and cooperate in adult life" (Brittain & Lowenfeld, 1987, p. 306). These groups are commonly comprised of the same sex

and the child has a growing awareness he/she can accomplish more in a group than by oneself. It is during this stage

children become more aware of surrounding details, yet, more self conscious of drawings rendered. Early during The Gang

Stage, children do not understand shading, and events are characterized rather than depicted naturally. Drawings

begin to show perspective as indicated by the emergence of a plane and the overlapping of objects. People and objects

become interrelated and the sky drops to the horizon. Figures become increasingly stiff and the child's schema is no longer rigidified. Body parts retain their meaning when

separated and less exaggeration, omission and emphasis on them is present. Later, in The Gang Stage, children begin

to desire a naturalistic component to their drawings. Understanding a child's creative development is important when observing art work (Brittain & Lowenfeld,

39

1987).

Irregularities and abnormalities in drawings may

indicate a child is experiencing a developmental delay or emotional difficulties (Brittain & Lowenfeld, 1987,- Rubin, 1984). To a verbal therapist these issues may remain at bay Harriet Wadeson

if a child chooses not to reveal them.

(1980) spoke of six advantages in which art therapy contributes or complements the psychotherapy process.

Advantages. Harriet Wadeson (1980) described the first advantage to art therapy as, "the image". We think in images. Prior to the development of

language a child is visually oriented and thinking occurs in images. We can say, therefore, that imagery

probably plays a large part in early personality formation, the core experiences which influence subsequent layers of personality development (Wadeson, 1980, p. 8). Imagery is also a primary component of what Freud termed, the unconscious (Santrock, 1995) . Art therapy can be conducive to "dreaming" on paper. Images drawn, like those

40

we dream, are loaded with unconscious material. Wadeson (1980) quotes Freud (1959) as saying:

Harriet

We experience it (a dream) predominantly in visual images,- feelings may be present too, and thoughts interwoven in it as well; the other senses may also experience something, but nonetheless it is predominantly a question of images. Part of the

difficulty in giving an account of dreams is due to having to translate these images into words. "I could

draw it," a dreamer often says to us, "but I don't know how to say it" (p. 8). Harriet Wadeson (1980) cites the second advantage to art therapy as, "decreased defenses" of the artist. Language is our primary mode of communication thus, we are knowledgeable in how to defend ourselves verbally. less conventional means of communication. Art is a

As a result, when

an artist works he/she has less control over this process of communication and often "slips of the tongue" or "slips of the brush" will occur (Wadeson, 1980) . Wadeson (1980) describes the third advantage to art therapy as, "objectification". This process occurs when

feelings or ideas are first externalized onto an object.

41

"The art product allows the individual, while separating from the feelings, to recognize their existence" (Wadeson, 1980, p. 10). As a result, the artist may learn to own the feelings once denied and internalize them as an intricate part of the self. Wadeson's (1980) fourth advantage to art therapy is, "permanence". Our primary mode of communication is language Words

and words are not permeable, unlike art products.

disseminate once spoken, yet art can be saved and reviewed, allowing new insights to develop. Old art work can be

resumed to remind both the artist and therapist of the feelings present during it's creation. Art work can provide

documentation of issues and their affectual components. Harriet Wadeson's (1980) fifth advantage of art therapy is, "spacial matrix". Images are spacial in nature, while

language is linear and functions under sets of rules. Images depict relationships simultaneously. Art work can

show closeness and distance, similarities and differences, and bonds and divisions through a spacial matrix (Wadeson, 1980) . Wadeson's (1980) last advantage of art therapy is, "promotion of creative and physical energy". It has been

42

noted by Wadeson (1980) that during an art therapy session discussions are much livelier than in a verbal group therapy session. Frequently, a change in energy level is quite

evident following the process of art making (Wadeson, 1980).

Appropriate Art Media, Before art making can occur, art materials need to be accessible. For individual's who have never had an art

therapy experience, it is necessary to have easily and quickly manipulated materials (Naumburg, 1966). In early

therapy sessions individual's should be given a structured and safe atmosphere in which repressed emotions can be expressed freely and comfortably (Naumburg, 1966; Rubin, 1984; Wadeson, 1980). Experience has shown that certain art

materials are the most suitable for releasing spontaneous art expressions easily and quickly (Naumburg, 1966). Semi-

hard pastels, poster paints may help promote the expression of affect while maintaining moderate structure (Naumburg, 1966; Wadeson, 1980). "Wide soft pastels in a wide variety

of colors are my happy medium-neither too tight or too loose and easily cleaned up" (Wadeson, 1980, p. 18). In choosing materials to achieve an experience of regression, clay and

43

finger paint should be considered (Rubin, 1984) . Rubin (1984) states it is generally best to allow children choice of their own art materials. Although she agrees at times,

it is necessary to offer options. Sometimes it is a technical matter--letting the person know that a thin brush is available and will work better for the picture he has sketched out, or that plasticine may be more appropriate than water based clay for the sculpture he has in mind (Rubin, 1984, p. 108) . Wadeson's (1980) approach to selecting art media differs from Judith Rubin (1984). While Rubin (1984) finds comfort

in an open and nonstructured art therapy session, i.e., children choosing their own media, Wadeson (1980) offers more structure. She states, media should be selected

purposefully (Wadeson, 1980). An art therapist may use a variety of materials. should be selected purposefully. Media

In a relatively loose

studio set up, art supplies might be arranged for the patient's choosing. If the art work is a vehicle for

free association and group communication, relatively fast media such as crayons, pastels, or felt tip pens

44

are most suitable.

Two important considerations in the

selection of media are the dimensions of facilitation and control. A sufficient variety of colors, adequate sizes of paper, and enough clay should be provided, along with adequate working space to facilitate spontaneity. Frustrating material should be avoided

such as newsprint which tears easily if pressure is applied to it. Different media are more easily Pencils lend themselves to

controlled than others.

tight control while watercolors and clay are more difficult to control due to technical problems regarding manipulation. Different materials evoke

different expression and the art therapist must be aware of the differences so appropriate media can be selected for the appropriate client {Wadeson, 1980, p. 18) .

Learning Through Art. Brittain and Lowenfeld (1987) state, the use of art materials stimulates our senses, which is basic to learning. It is only through the senses that learning can take place. This may sound like an obvious statement;

45

however, it's implications seem to be lost in our educational system. Schools have done little to

educate these senses that are our only avenue to learning. Touching, seeing, hearing, and tasting

involve the active participation of the individual. Art is filled with the richness of textures, the excitement of shapes and forms, the wealth of color, and youngster and adult alike should be able to receive pleasure and joy from these experiences (Brittain & Lowenfeld, 1987, p. 11). Lusebrink (1990) agrees art materials stimulate our senses and promote learning. Vivid sensory experiences lead to She speaks of colors

more vivid memory (Lusebrink, 1990).

as visual stimulators and paint as lending itself to vivid color explorations and a tactile experience. A slow

movement of the hand over the paper surface with the eyes closed establishes a contact with the sensory level of experience, as does also, the temperature and texture of an object or art material {Lusebrink, 1990). Basically, art is

a means of promoting perceptual growth (Brittain & Lowenfeld, 1987).

46

The cultivation and growth of the senses are important parts of the art therapy experience. This is of vital

importance, for the enjoyment of life and the ability to learn may depend upon the meaning and quality of sensory experiences. In creative activity, increased

perceptual growth can be seen in children's increasing awareness and use of perceptual experiences

{Brittain & Lowenfeld, 1987, p. 63). In addition to providing perceptual growth, art therapy has the capability to increase emotional growth, intellectual growth, physical growth, i.e., motor skills, creative growth, aesthetic growth, and social growth (Brittain & Lowenfeld, 1987). Regarding art and the social growth of a child, Brittain and Lowenfeld (1987) write, The art process itself provides a means of social growth. Art has often been thought of primarily as a

means of communication, and as such it becomes a social rather than a personal expression. The drawing can

then become and begins to encompass others in the viewing of the subject matter. This feeling of social

consciousness is the beginning of the understanding of

47

the larger world of which the child is a part. {Brittain & Lowenfeld, 1987, p. 65). Moreover, art therapy groups offer children the opportunity to assume responsibility for their actions in a cooperative activity promoting social growth (Brittain & Lowenfeld, 1987; Silver, 1989). Case (1948) writes about an art

therapy group experience promoting socialization with latency aged children. When working with children within a

group, she follows individual psychological theory rather than group theory. She feels the group is useful for a Moreover,

child's social development and understanding.

the children often take in the therapist's model of relating and accepting others differences. Case {1948) believes the

trust that is established enables the children to understand and help each other. Silver (1989) spoke of the art experience as empowering. "It can enable a child to compare himself with

others, and find himself adequate, it can help him control his behavior and maintain emotional balance" (Silver, 1989, p. 39). When studying children who have difficulty verbalizing anger and venting frustrations Silver (1989) stated,

48

Without an outlet for expression anger can turn to rage. Like the tragic dramas of ancient Greece,

drawing and painting can serve as catharsis, restoring inner harmony and balance .... The children studied followed up angry drawings with drawings that seemed to reverse the action. For example, Larry made a pencil

drawing of a man and woman, then painted wounds on their faces, and finally painted stitches on the wound. If he had repressed his anger at the people he represented, he might have turned it on himself. had expressed punished. anger directly, he might have been If he

The fact he undid the damage suggests his

anger had been spent, at least for a while (p. 37). Silver (1989) discusses learning disabled children and the ability art expression lends to relieving their tension. The child who is inarticulate has difficulties persuading others or even letting his wishes be known, but as a.painter he can be powerful. He can punish

villains and reward heroes, and change painful experiences into pleasant ones. A child has the

ability to experience control over people and events (p. 42) .

49

Silver (1989) pondered questions such as, Would drawing pictures enable a child to sustain thoughts he cannot verbalize? and Can art procedures lead children to fundamental mathematical or logical ideas that are usuallylearned through language? As a result of his questioning,

Silver (1989) documented learning disabled children who acquired such concepts as verticality and horizontally and the improvement of abstract thinking through image making. Art and it's effect on a child's cognition was a focus of Silver's (1989) research. She hypothesized that memory

recall would be greater when information is organized into structured forms such as sentences or drawings. "Like a

sentence, a drawing or painting is a structured form, and it too can help preserve what might otherwise vanish" {Silver, 1989, p. 25). When a child puts knowledge into a concrete art form, recall is greater (Silver, 1989). The art

experience serves to integrate new information and demonstrate what has been learned. learning can occur. Then, a transfer of

This is the process of applying

knowledge learned through the art process to other areas in one's life (Silver, 1989). "To the extent a child

spontaneously draws a picture about something he has learned

50

elsewhere, he is using that information in his own way for his own purposes and applying it appropriately to a new situation" (Silver, 1989, p. 18). Silver (1989) noted a student's transfer of positive attitudes from art class to homeroom class. Lusebrink (1990) writes regarding an individual's cognition and it's correlation to the art experience. has been concluded, the development of a drawing and/or visual expression is a predominantly cognitive problem solving activity (Auly, 1986; Golomb, 1992; Lusebrink, 1990; Silver, 1989). Different aspects of a problem can be It

represented through the choice of different simple shapes {Lusebrink, 1990). Clients often express their inability to choose, feeling of paralysis of will. Once the art work is

done, the client and I count the many choices that had to be made. Perceived weaknesses around the area of

decision making are confronted, demonstrating the power to choose resulting in empowerment. This empowerment

can than be generalized to other areas of daily living (Franklin, 1992, p. 81).

51

A. Markus (1988) studied art and it's influence on the child's problem solving skills, memory and learning. Students were required to draw pictures of words, statements, and arithmetical problem solutions within an allotted time. Students who drew more pictures were more

successful in the reproduction of words due to the active use of verbal and visual codes. It was suggested that

greater depth of processing was conditioned by the greater number of drawn pictures. It has been proposed, the greater

the involvement in the art process, the more information retained, and the greater the potential for learning (Markus, 1988,- Silver, 1989). Puson and Gordon (1989)

conducted a similar study regarding the effect drawing has on a child's problem solving skills. Teachers successfully

helped second graders learn to use schematic drawings to solve a wide range of addition and subtraction word problems containing three digit numbers (Fuson & Gordon, 1989). Moreover, each time a child exercises his/her right to choose, during the art process, problem solving and decision making skills are being reinforced (Franklin, 1992). Decision making skills are learned both intrapersonally and interpersonally during an art experience. "When

52

creating art one can not help but look inward and participate in decision making that is targeted at the resolution of emotional and cognitive processes" (Franklin, 1992, p. 79). This is a powerful tool which validates and empowers the uniqueness of the group member. Empowering

group members may lead to increased self-esteem, assertiveness, and ego development 1989). (Franklin, 1992; Silver,

Joan Bloomgarden, MA, A.T.R. and Frances F. Kaplan,

DA, A.T.R. (1993) used visualization and art to promote ego development in group therapy. Bloomgarden and Kaplan (1993)

designed an art therapy procedure which promotes specific aspects of ego development, such as, enhancing self-esteem, improving interpersonal relating and increasing awareness of personal values. These goals were addressed through guided

imagery techniques and relaxation/stress reduction.

Creative Arts Treating Addictions. Although there is no known research regarding art therapy in prevention of substance abuse, the creative arts have been utilized in the treatment of addictions. in fact,

the creative arts and mind-altering substances are said to share close ties.

53

Both have been hailed as opening the "doors of perception" and creative artists have often used stimulants to access inner images. Can it be said that The questions

creativity is an antidote for addiction?

are, Do creative expression and addiction support each other? or Can creativity become a replacement for addiction, as a kind of homeopathic alternative? (Johnson, 1990, p. 295). Although researchers such as Johnson, have not proven the creative arts to be a viable alternative to substance abuse, art expression has still been used in the treatment of chemical dependency. Lynn Johnson, MS, RDT, CAC, (1990)

proclaims the creative arts therapist, in the treatment of addictions, calls, assists, models, guides, encourages and inspires creativity and self-expression. "We write a poem,

we draw a picture, we act in a play, and we come a little closer to understanding ourselves, to forgiving ourselves, to healing ourselves" (Johnson, 1990, p. 231). Jullaird,

MA, MFA, (1994) further discusses art therapy in chemical dependency treatment. She writes,

While few art therapists receive specific training in chemical dependency treatment, a number of them have

54

adapted their discipline to this population.

Friedman

and Glinkman (1986) affirmed the success of this approach, demonstrating an art therapy component in adolescent drug abuse treatment programs was associated with higher success rates. The appeal of using art

therapy in chemical dependency treatment is that art can bypass conscious defenses and enliven treatment. For example, Treder-Wolff (1990) stated that "the dynamic, open-ended nature of creativity is a threat to the rigid, self perpetuating addictive system. Art

therapy can offer diverse approaches to treatment, but, as emphasized by Allen (1985), art therapy should clearly focus on the same treatment goals as the rest of any chemical dependency treatment program "If

patients receive the same messages in different mediums, the likelihood of change is greater," she asserted. Moore (1983) listed curative transference

among the goals for art therapy in substance abuse treatment, suggesting that energy be directed toward more positive activities, exploring group roles and interactions, increasing self awareness, allowing access to nonverbal modes of communication, supporting

55

the switch from reaction to action, integrating function of the right and left hemispheres of the brain, expressing emotions, and responsibility. to achieve these goals are numerous. Mackay Ways

(1987),

for instance, explored the emergence of unconscious material in cocaine and heroine addicts through a combination of art and drama therapy. Virshup (1985)

found conducting art therapy sessions in a methadone clinic lobby offered clients a nonthreatening way in which to communicate feelings, deal with conflict, and improve both self-esteem and social skills. Springham

(1992) explored the use of nondirective art therapy with substance abusers and identified stress release, ego development, insight, and occasional "deep work" as its benefits for patients. Nondirective expressive

therapy was also was also successful in increasing creativity among chemically dependent individuals (Ryder, 1986). (Julliard, 1994, p. Ill). In 1983, Rosanna W. Moore, MA (1983) reviewed approximately twenty items of literature on art therapy and substance abusers. She has concluded, whether the drug

stimulates, relaxes, or numbs, the individual uses it out of

56

a desire to feel that control of one's own feelings lies in one's own hands (Moore, 1983) . Moore (1983) asks each patient to act with the art materials instead of acting on one's body with pills and needles etc. Inherent in art

therapy is the patient's active participation in his/her own treatment (Franklin, 1992; Moore, 1983,- Rubin, 1984; Wadeson, 1980) . A sense of control is enhanced through the tangible media and through being able to manipulate the issues symbolically. By making issues either symbolic or

concrete, art makes them more accessible for discussion. Because it enhances the quality of

communication and reduces confusion, the artwork facilitates mastery and understanding. The tangible

nature of the artwork aids in recognition and reduction of distortions. It provides the patient and therapist For the substance abuser, who

with a new perspective.

often seems to avoid experiencing and acknowledging his/her real feeling, the form of artwork is available as an aid in recognizing different feeling states. Unrecognized attitudes may be brought into awareness through art more easily than through language, because

57

the patient doesn't use his/her well practiced defenses. Clarification of matters the patient brings

up in art therapy may give the substance abuser an increased sense of mastery over them. Not feeling so

confused by his/her problems, the patient experiences them as less overwhelming. By taking ownership of

his/her own expressions, the patient also takes ownership in a way to learn about himself (Moore, 1983, p. 251).

Art Therapy in the Public Urban School. Although art therapy has traditionally been utilized in inpatient hospital and day treatment settings, it now has become an intricate part of the public school system in Miami, Florida. Janet Bush, Ed.S., A.T.R.-BC (1995) of Dade

County Public Schools in Miami, has introduced a clinical art therapy program for exceptional students. She

personalizes art therapy to fit each student, addressing their individual needs. Students are evaluated, then Bush

assigned to a group or one-to-one treatment session.

(1995) works in conjunction with teachers, parents, school

58

support personnel, and school psychologists in providing students with appropriate treatment. In the Dade County School System, art therapy is a therapeutic intervention which helps students symbolically explore, organize and assimilate meaning from a complex world of ideas and experiences. Healthy communication and

social skills are fostered, as well as, affective development which can aid students in becoming more receptive to learning. Art therapy can offer students

distance from disturbing thoughts and feelings or help to connect feelings and thoughts. barriers. It can also surpass language

Bush (1995) cites obstacles to providing art

therapy in a school setting as being, a lack of awareness of art therapy and it's benefits, an unclear plan for the utilization of art therapy services and a lack of mechanism for hiring art therapists. In 1980, Bannasch, Chin, Chin, Cross, Palombo, and Palombo, began an early intervention program with students whose low level of confidence, self image and social skills either inhibited their own efforts to be "mainstrearned" or exaggerated their learning or behavioral disabilities among their teachers and peer group. This program, termed Project

59

Reachout, utilized art and video as a means to help students communicate their problems while developing social skills in an actively creative atmosphere. The use of art activities

provided a methodological framework, creating a nonthreatening and communicating atmosphere. The two groups of

teenage underachievers experienced a four week therapy program combining social skills training, art therapy and video techniques. Significant increases in self-esteem were

noted by students themselves and significant improvements in their interpersonal skills were noted by therapists. Although further studies are needed, the results of Project Outreach were encouraging (Bannasch, Chin, Chin, Cross, Palombo, & Palombo, 1980}.

60

Early Intervention/Prevention Programming

United States Health Care Reform. In early 1993, the United States began a broad-based reconsideration of its health care system. attempted reform took many paths. The

At the most viable

level, the Health Care Task Force of the Clinton administration began to redesign the system from the bottom up. The Clinton plan is directed at providing

access to health care for all citizens by mandating competing managed care plans. Basic services will be

offered on a capitiated basis and the private insurance market will be significantly smaller. When this

occurs, much of the traditional support for public health delivery programs will erode. Programs such as

community and rural health centers, public hospitals and the federal and state grants that have supported them will slowly disappear. The large number of health

professionals and clinicians employed will have to learn a new set of managerial skills in order to succeed.

61

As the health plans enroll larger populations that are financed on a capitated basis, they will have to develop population health competencies, well beyond what is in existence today. Public health education in

prevention is a principal source of this professional competence. While most health care professionals focus on providing treatment to individuals for acute illness, it is the public health professional who provides special skills in health education. This will be

critical in developing and implementing strategies to maintain quality health care outcomes, lowering costs, and keeping patient satisfaction high. Community-wide health education, as well as, disease prevention and wellness programs will have new support, as these programs will dramatically affect health care plans. Complex and interrelated problems such as teen

pregnancy, violence and chronic substance abuse can be linked to systematic issues such as education, employment and housing. If the public health

professional focuses on these issues and other health care concerns before they become critical, the affected

62

enrollees will be handled more effectively than they are with current measures. In many ways, health care reform offers a chance for a renaissance of the public health profession. This will come about only as the professionals and schools effectively adapt to the inevitable changes in the health care system. Health care reform will need

to integrate a system of prevention with primary care (O'Neill, 1995, p. 11). It is important to fully understand the distinction between prevention program planning and treatment services. Creative Arts Therapy is by Michel (1976)

definition a treatment oriented process.

defines therapy as a systematic process which brings about healing, or change from undesirable, unhealthful conditions to more pleasant or healthful ones. Caplan

(1964) defined prevention as the activity by community mental health professionals that lowers the rate of new mental disorder cases by counteracting harmful circumstances before they have a chance to produce illness. ... Well planned prevention programs that can assist Americans with the daily emotional stresses that

63

often lead to physical illness, depression, substance abuse, and family violence. Such programs would be

cost effective both in terms of dollars and in terms of human suffering {Wager, 1987, p.135).

Existing Prevention Programs. In response to the need for well planned prevention programs, K. Wager (1987) integrated the creative arts modalities of music and psychodrama in a prevention program. She advocates, Prevention programming calls for methods that impart cognitive information, enable affective responses that can lead to behavior change, and increase opportunities for learning new coping skills. Music and drama can be

excellent media for such programs precisely because both art forms have the potential to involve participants cognitively, affectively and physically, thus enhancing the learning experience (Wager, 1987, p. 137) . This prevention program was designed and implemented within an elementary school by Wager (1987) and specialists at Substance Abuse Services Of New River Valley, Blackburg,

64

Virginia.

It utilized music and psychodrama as a

complementary approach to substance abuse prevention. Teachers found the project helpful for approaching a difficult topic-use and misuse of drugs. They noted the

children were highly attentive, enjoyed the program, and retained the information presented. Many stated the

creative arts were an effective way to enrich the children's classroom experience and enable them to discuss feelings about difficult situations this program was successful. (Wager, 1987). The outcome of

It has been operating for five The

years and continues to be well received at the schools. success prompted a grant from the Virginia Division of Health Education. Although creative arts therapists are

trained to work primarily in treatment centers, Wager (1987) calls for creative arts professionals to consider applying their knowledge to preventing mental illness and promotion of community health. Richard Walsh, PhD (1990) responded to

this need. Walsh (1990) states, utilizing the creative arts in school programs rather than clinics, maximizes the therapeutic impact of promoting social and emotional growth. He conducted a creative arts program in social skills training for early adolescents. Although this program was

65

not a controlled field experiment nor a systematic qualitative study, overall findings suggest that most of the group members made some gains in social skills development. During a 1987 National Conference on preventing alcohol and drug abuse in black communities, Roy W. Pickens, Ph.D. spoke about the treatment of acute substance abuse and our communities' need for prevention programming. Treatment is one of those things with which it is very difficult to deal. People admitted into treatment

programs do not always do well in those programs. They certainly do better if than if they do not go into treatment. However, what we would like to do is avoid Obviously, if you can

the problem in the first place.

avoid the problem than you do not have the disruption that would occur in the person's life, in the family and in society (Pickens, 1987, p. 21).

Effective Strategies. He continues his remarks by advocating the need for effective prevention programs targeting substance abuse. Effective strategies need to be utilized in preventing alcohol and drug abuse. Not only will these strategies

66

prevent substance abuse, but we also are preventing so many other diseases that run along with drug abuse. One of the most obvious of these is AIDS, but there are a lot of other diseases that are also associated. I

cannot think of anything more important right now than to apply prevention efforts in the community and within the family, to decrease the use of drugs, because in so doing, not only are we decreasing drug abuse, but we also are decreasing the risk that an individual runs for AIDS and other physical and mental illness (Pickens, 1987, p. 22). Bush, D'Elio, Iannotti, and Mundt (1993) agree that substance abuse early intervention programs may reduce future health problems. Even moderate adolescent drug use

is significantly related to decreased physical hardiness in adulthood (Bush, D'Elio, Iannotti, & Mundt, 1993). It has

been suggested that promoting a healthy lifestyle could be an important method of intervention. Bush, D'Elio, Ianotti,

and Mundt (1993) taught healthful behaviors to urban preadolescents. Their hypothesis was, "If behaviors known

to strengthen health are initiated or enhanced, health compromising behaviors such as substance abuse would be

67

reduced" (Bush, D'Elio, Iannotti, & Mundt, 1993, p. 354) . The findings suggest that although positive health behaviors appear to be inversely related to abusable substance use in urban preadolescents, the relationship may be spurious. Bonnie Benard, author in Preventing Alcohol And Other Drug Problems Among Youth In The Family, reviews the characteristics of effective prevention programs. Benard

(1993) and Wager (1987) state, program comprehensiveness and intensity are important. Donaldson, Graham, and Hansen

(1993), facilitator of school based alcohol prevention programs agrees that effective programs are comprehensive in that they address multiple systems and use multiple strategies. Multiple systems may include schools, community Prevention efforts which

organizations, and families.

target a variety of systems are more effective than those focusing on one system, i.e, school and home. Multiple

strategies may include, dispensing information regarding the effects of drug abuse, challenging normalized beliefs, developing life skills such as problem solving, decision making, assertiveness, coping with anxiety/stress, and developing self esteem (Albrecht & Rosella, 1993; Bailey, 1988; Berdiansky, 1991; Bernard, 1993; Donaldson, Graham, &

68

Hansen, 1993; O'Connell, 1989; Silverman, 1990). also been termed affective education.

This has

Information dispensed should focus on the short term effects of gateway drug abuse due to the difficulty latency age children have in abstract thinking (Arkin & Funkhouser, 1990; Bernard, 1993) . A working knowledge of the effects alcohol, marijuana and nicotine have on the mind and body is of utmost importance, as is the symptoms of their use {refer to Gateway Drug Abuse section of Literature Review). U.S. Department of Education (1992) states, at a bear minimum one should know the dangers associated with gateway drugs, be able to identify paraphernalia, be familiar with street names of the gateway drugs, know what the drugs look like and be alert to changes in a child's behavior/appearance indicating gateway drug abuse (refer to Gateway Drug Abuse section of Literature Review). ^Effective prevention programs are part of a broader, generic prevention effort to promote health and success" (Benard, 1993, p. 1). Jessor concluded, in his 1984 study, that prevention efforts focusing on changing one behavior will probably not work (Arkin & Funkhouser, 1990; Bush, D'Elio, Iannotti, & Mundt, 1993). As previously stated, The

69

health-compromising behaviors tend to be interconnected and to have common antecedents. Effective prevention programs should provide sufficient prevention efforts (Benard, 1993). Adequate time per

strategy and adequate numbers of strategies should be utilized. Benard (1993), via the U.S. Department of Health

and Human Services states, if anything is to be learned in the last decade, it is that solitary prevention efforts do not work. In addition, programs should be long term and if

possible follow the children through life stages (Benard, 1993; Donaldson, Graham, & Hansen, 1993; Goplerud, 1991; U.S. Department of Education, 1992). Effective prevention activities should be integrated into family, classroom, and community life {Benard, 1993; Sanchez, 1987). Integrated activities remain more an ideal

than a reality for many programs, yet, a prevention strategy which integrates drug abuse prevention activities into daily life is highly effective (Benard, 1993). Prevention/early intervention programs use an array of strategies. Benard (1993) via the U.S. Department of Health

and Human Services, classifies information strategies as those which address knowledge, attitudes, and skills as a

70

set, provide alcohol and other drug-specific knowledge, and focus on the prevention of gateway drugs. Materials used to

convey messages should be culturally/ethnicity sensitive, appealing and appropriate for the targeted population, focusing on the short terra effects of substance abuse, and utilizing different modes of learning, i.e., auditory, visual (Bernard, 1993; O'Connell, 1989).

The Alternatives strategy provides positive alternatives that serve functions similar to or more highly valued than those served by health-compromising behaviors (Bernard, 1993; Botvin & Botvin, 1992; Johnson, 1990; Wager, 1987). The goal of this type of strategy is to offer

a stimulating and healthy alternative to drug abuse. According to Botvin and Botvin (1992), youngsters engage in problem behaviors such as substance abuse because it may serve as a way of coping with environmental and developmental stressors. Perhaps it enhances their public Children need to be taught

image or portrays independence.

healthy alternatives that will provide a natural high, curb the needs being satisfied through drug use, and function as a coping mechanism (Bernard, 1993; Botvin & Botvin, 1992). Goplerud and The Office of Substance Abuse Prevention

71

(1991), cite Tobler (1986), as defining two categories of alternative programs. The first emphasizing positive

activities which are more appealing than drug use and the later aimed at enhancement of competence to overcome deficits in life skills, i.e., low self esteem and increase individual's sense of control over his environment (Botvin & Botvin, 1992; Goplerud, 1991). Tobler concludes,

alternative programs were shown to be highly successful for the "at risk" adolescent such as drug abusers (Goplerud, 1991) . Teaching life skills is also a strategy utilized to prevent gateway drug abuse combining a cognitive and affective approach (Benard, 1993,- Donaldson, Graham, & Hansen, 1993; O'Connell, 1989; Silverman, 1990). Benard via

the U.S. Department of Health and Human Services (1993) states, an effective prevention program focusing on the development of life skills should include training in communication/social skills, problem solving and decision making, critical thinking, assertiveness, resistance, peer selection, low-risk choice making, self improvement, stress reduction, and consumer awareness (Albrecht & Rosella, 1993; Johnson, 1990; O'Connell, 1989; Silverman, 1990) . Consumer

72

awareness is an important factor in prevention programs. The ability to analyze and evaluate media messages and advertising is crucial if youth are to resist the powerful pro-use message promulgated through advertisement (Benard, 1993}. A program offering training in life skills takes an

affectual approach, enhancing interpersonal relationships thus, intimate relationships lay a foundation for support. Vaughan & Wills {1989) studied social support and substance use in early adolescents. Results showed, an increase in

social support by drug free peers resulted in a decrease in drug use. Typically when fostering social support, verbal

and nonverbal communication is explained, focusing on difficulties regarding boy/girl and parent/child relationships. Problem Solving and decision making skills

help build self-esteem and critical thinking helps build a bridge between the artificially separated emotional and intellectual domains of learning. Botvin and Botvin (1992)

focused on assertiveness training in his successful Life Skills Training Program. He states, "assertiveness training

is an essential strategy for building self-efficacy" (Botvin & Botvin, 1992). Also, training in assertiveness may lead resisting peer pressure.

to healthy resistance skills, i.e.,

73

Bennie Crayton (1987), speaker at the National Conference on Preventing Alcohol and Drug /Abuse in Black Communities states, "we know in the area of prevention that perhaps the most important thing is the question of self-esteem. Many

of the drug and alcohol prevention efforts over the last 20 years have been aimed at enhancing and supporting selfesteem" (p. 22). Bettina Scott Ph.D. (1987), another

spokesperson for the prevention of alcohol and drug abuse in black communities, agrees building self-esteem is important in prevention efforts. She states, "Positive image building

helps black, urban children improve their grades in school and gives them attention as young people. It offers them

the opportunity to make their own life plan" {p. 25}. Similar to the Life Skills strategy is the behavioral domain approach {Greenwood, 1992). This approach attempts

to train youth to resist peer pressure or media pressure encouraging substance use. This has proven to be the most

promising strategy over the past decade, using a variety of social skills approaches based on Bandura's theory of social learning. Substance abuse prevention programs based on this

concept attempt to help individuals identify factors that might encourage their likelihood of substance abuse, acquire

74

appropriate skills for resisting this pressure, and develop confidence these skills will work. More recently, a number

of programs using social influences concepts alone or in combination have shown modest reductions in marijuana use that hold up for one to two years after baseline (Greenwood, 1992) . Research by Donaldson, Graham, and Hansen {1993)

shows drug prevention programs based on theories of social influence often prevent the onset of drug use. Another strategy used in prevention/early intervention programs is skilled and credible delivery by individuals who potentially would function as role models (Bernard, 1993). Credibility and skill can be earned through good preparation, effective communication, group facilitation, comfort with the materials and the target audience, supportive personalities, appropriate behaviors and social interaction (Vaughan & Wills, 1989). The facilitator must

be clear and consistent when communicating expectations for behavior and addressing the problem of gateway drug abuse {Benard, 1993). An educational/information approach to preventing substance use is common. This cognitive approach includes

efforts to provide youngster's knowledge about the effects

75

and hazards of substance use and actual usage rates among their friends. Teaching about drug paraphernalia, short and

long term physical and emotional effects of use, and various forms and names of drugs is common (U.S. Department of Education, 1992). Yet, a large number of experimental

projects directed at this approach alone failed to show any effect on outcomes related to substance abuse (Greenwood, 1992} .

Planning a Program. After reviewing characteristics of effective programs and different strategies for prevention, becoming familiar with a target population, and having a working knowledge of gateway drugs, planning a program can begin. Little

research has been done on the planning process and on identifying the planning stage of a prevention program. In

Preventing Alcohol And Other Drug Problems Among Youth In The Family, Benard under The U.S. Department of Health and Human Services (1993) cites, "Effective programs follow a sound planning process consisting of needs assessment, goal identification, implementation, management evaluation and replanning" (p. 7). Because of poor research results,

76

prevention facilitators have to rely on experience, good planning, and problem solving (Benard, 1993}. It is

important for all program coordinators to communicate and if possible all local systems, i.e., teacher, therapist, The research

family, peers (Benard, 1993; Bush, 1995).

literature often calls for more collaboration among prevention professionals from various disciplines, mental health, education (Benard, 1993). i.e.,

Goals must be

realistic and measurable for the purpose of program evaluation. Changes in a child's behavior or drug and

alcohol use requires a long term commitment and a community wide effort (Bernard, 1993; Bush, 1995). Short term goals,

i.e., academic success should be acknowledged and processed with the child (Benard, 1993; Donaldson, Graham, & Hansen, 1993). The U.S. Department of Health and Human Services

(1994) states, effective prevention programs make recommended changes as a result of evaluation feedback. Being flexible is necessary for program success, as well as, educating the community and institutions consistently on the program and its effectiveness (Bush, 1995).

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Target Population: Latency Aged Children In Urban Areas

A former drug dealer discusses the growth of the drug culture, among latency aged children in urban areas-You know, I had these boys, eight, nine, ten, eleven, twelve [years old], ask me for rolling [cigarette] paper. I was shocked. I said, "How old are you?". He

said, "I'm ten".

I said, "Man you're crazy.

What are

you going to do with paper?" Eight, nine, ten, years old. know they did it that young.

"Smoke a joint, man." I was shocked. I didn't

Ten years old?...You

should have seen him sitting like this [pretends to roll a joint], rolled that shit like a pro, two hands and tongue in it. I said, "Jesus. Oh, my god." That

freaked me out, that did. (Anderson, 1990, p. 83) .

The Urban Community. The inner city is increasingly characterized by substandard housing, inferior schools, inadequate health care, female headed households, lack of

78

legitimate opportunity, and welfare dependency {Garbarino, Dubrow, Kostelny, & Pardo, 1992; Gibbs, 1988,- Prothrow-Stith, 1991). There has been a rapid

rise of serious violence in these communities (Gibbs, 1988): Escalating numbers of youths are exposed to

episodes of community violence either as witnesses or victims or have known victimization of a close friend or relative (Safyer, 1994) . These impoverished urban neighborhoods generate chronic levels of stress for today's "inner-city" youth. As a

result of poverty and discrimination, high levels of problematic psychosocial behaviors and psychological and behavioral disorders have developed among urban youth {Albrecht & Rosella, 1993) . "Many urban youngsters find

some relief from environmental stress by engaging in substance use and abuse, unprotected sex, criminal activity, and acts of violence" (Safyer, 1994, p. 154). The most distressing social indicators are the startling statistics on the extent that juvenile delinquency and exposure to violence have become a part of daily life in many urban neighborhoods. Homicide is the leading cause of death among

urban black males, ages fifteen to nineteen years old and

79

has been since 1969 (Albrecht & Rosella, 1993).

Albrecht

and Rosella (1993) cite, more adolescents die from violence, especially gun violence, than from any illness, Exposure to violence, whether it be on the street or in the home, has been noted as a risk factor contributing to potential drug abuse (Anderson, 1990; Bailey, 1989; Brown, 1990; Brown, Dembo, Schmeidler, Williams, & Wothke, 1992; Danish, Farrell, & Howard, 1992; Greenwood, 1992; Schubiner, Scott, & Tzelepis, 1993). Howard Schubiner, M.D., Richard

Scott, M.A., and Angela Tzelepis, Ph.D. (1993) conducted a study, regarding the exposure to violence among urban youths. Inner-city youths were surveyed regarding their Forty four

exposure to and participation in, violent acts.

percent of the children stated they could access a gun within one day while forty two percent had watched someone knifed or shot. Twenty two percent of the children had seen

someone killed, eighteen percent recorded carrying a gun and thirty two percent had been involved in physical fights. These statistics show inner-city youth to have frequent exposure to violence which in turn increases chances for potential involvement in substance abuse. (Anderson, 1990; Danish, Farrell, & Howard, 1992; Greenwood, 1992; Sabol,

80

1991; Safyer, 1994; Schubiner, Scott, & Tzelepis, 1993). "Prothrow-Stith (1991) reports that'...by age 11, four out of five of the children have seen someone beaten up either at home or on the street. shooting or stabbing. One out of three have seen a

One quarter had seen a killing' (p.

63)" (Safyer, 1994, p. 154). This toxic violence can lead children to feel their homes are no longer "safe havens". As a result, many children do not sleep at night and find it difficult to concentrate in school (Safyer, 1994) . In attempt to understand the stress coping framework among black urban youth, Albrecht and Rosella (1993) describe social stressors in the urban environment. Youth

from low income backgrounds experience more major stressors in their lives, and these events are perceived as more disruptive for them than for their affluent counterparts (Albrecht & Rosella, 1993). Low income neighborhoods, such

as the urban setting, are filled with distrust, hostility, inadequate housing, and a lack of positive role models (Albrecht & Rosella, 1993,- Anderson, 1990; Greenwood, 1992; Monye & Oyemade, 1990; Sabol, 1991; Safyer, 1994) . "Surroundings are often inhabited by prostitutes, drug addicts, criminals and juvenile delinquents, with a

81

hostility toward the police, a sense of alienation from society, and a feeling of victimization" (Albrecht & Rosella, 1993, p. 199). For the poor, cities are often a prison. choice about living where they do. Many have no

Poor families have

little access to the cultural and educational riches surrounding them. Their neighborhoods consist of

deteriorated tenements, many of them abandoned and surrounded by vacant lots filled with garbage and rats. Yet these lots and crumbling buildings are often the children's only playgrounds--if the drug dealers have not taken over first. Too many of their schools, with

barred windows and high fences, resemble jails, and too many of their educators are demoralized by overcrowded classrooms and scanty resources. In this environment,

it is profoundly remarkable that children survive at all. These children, the children of the poor urban

communities are at risk (Sabol, 1991, p. 60). The reality of urban life is, homelessness, substance abuse, crime, neglect/abuse, and lack of educational/employment opportunities (Sabol, 1991). The continuing lack of

educational and unemployment opportunities among city teens

82

have increased the potential for drug misuse (Albrecht & Rosella, 1993; Anderson, 1990; Bransfield, Friedman, & Kreisher, 1993}. These social ills are all direct

consequences of poverty in which these children live (Sabol, 1991; Monye & Oyemade, 1990) . In effect, the destruction of

countless children by substance abuse is the most stark example of the disintegration of these communities (Sabol, 1991; Safyer, 1994; Schubiner, Scott, &Tzelepis, 1993). Alcohol problems in particular, have long been especially associated with city life (Room, 1990) . Factors

such as poverty and exposure to violence have been observed as feeding the substance abuse epidemic in cities. Yet,

Room (1990) studied potential explanations of higher urban rates of alcohol abuse. Four possible explanations are: (a)

There may be a more complete reporting of problems in the city, (b) Problems may occur in the city, but may involve noninhabitants, (c) Migrants to the city may be especially attracted by or vulnerable to heavy drinking, and (d) Characteristics of city lifestyles are conducive to heavy drinking defined as problematic (Room, 1990) . Adams (1992) conducted a study he termed, "Is happiness a home in the suburbs?". This study discussed the

83

influences of urban and suburban neighborhoods on psychological health. Results showed, subjects in the

suburbs were no more likely to express greater satisfaction with their neighborhood, greater satisfaction with the quality of their lives, or stronger feelings of selfefficacy than people living in the city. Farrow and

Schwartz (1992) conducted a similar study comparing urban and suburban rates of alcohol and tobacco use among youth. Reports on drug and alcohol usage in urban and suburban pediatric practices showed suburban subjects to be heavier users of tobacco products and alcohol.

Social Support in the Urban Community. Conversely, Albrecht and Rosella (1993) proclaim the urban environment to be conducive to feeding the substance abuse epidemic. A mediating factor is the lack of

availability and quality of social resources and supports (Greenwood, 1992; Monye & Oyemade, 1990; Sabol, 1991}. Social support provided for today's urban youth has been related to positive dimensions of mental health (Albrecht & Rosella, 1993) . Judith Marks Mishne (1993) agrees that mental health is positively correlated to the availability

84

and quality of social resources in one's community.

She

writes about the dilemmas in provision of urban mental health services for latency age {six to twelve years old) children. She states, latency age children whom reside in

urban areas are at great risk of becoming the "violent adolescents of tomorrow" due to the break down and burn-out of urban psychological health facilities. Urban mental health facilities are increasingly overwhelmed by the sheer number of cases, at a time when federal, state and local funding cutbacks are greater than ever before. Addition to the number of

cases needing care, is a growing number of cases presenting overwhelming social problems i.e) emotional and medical pathology, economic deprivation, and substance abuse, with resultant family violence and child abuse...Many of the families seen are burdened by overwhelming social pathology, poverty, huge numbers of children per family, single parenthood, drugs, and neighborhood violence. Treatment is

increasingly difficult to provide, given the poor access to child serving systems. Worker burn-out in

response to overwhelming difficult cases and excessive

85

assignments, suggest a situation of crisis proportion. Professionals, battle weary, are retreating from agency practice, simultaneously with agency cutbacks of staff and service. Latency age children are among the most

vulnerable, caught in deteriorating schools and neighborhoods, living with incredible daily violence, and pressures from drug dealers, pushers, adolescent gangs, and inadequate supports in their homes. This

group of children is being pushed to become the violent adolescents of tomorrow (p. 271). These children have been forced to grow up prematurely without social support due to the environment in which they live. "Many cannot handle the stress of adult life and thus

become crime prone, aggressive, and generally unpredictable (Anderson, 1990, p. 77).

Social Impact of Urban Living. Elijah Anderson (1990), author of Street Wise and Professor of Social Sciences at The University of Pennsylvania, studied race, class, and change in urban communities. He proclaims, urban residents feel intimidated

by their streets, parks, and other public places,

86

particularly after dark or when too many strangers are present. He writes about the social impact of an urban

environment on today's youth. Today unemployment, crime, drug use, family disorganization and antisocial behavior have become powerful social forces. With severely limited

education skills, younger and poor blacks of the city are left with little chance to participate in the regular economy.. The jobs that do exist for them are Young blacks in To many

usually low paying or many miles away.

particular are caught in an unemployment bind.

young men, the underground economy of drugs looks attractive (p. 57). Anderson (1990) believes drugs and the drug culture have a prominent effect on today's urban youth. "Street smart

young people who operate in the underground economy are apparently able to obtain big money more easily and glamorously than their elders. Because they appear so

successful they become role models for still younger people" (p. 77) . Sometimes youngsters become involved with drugs for the money and other times they become involved for the rush of a "high". Among the kids there is sometimes a

87

strong desire, induced partly by peer pressure, to experiment, to try a certain type of high {Anderson, 1990)

Latency Aged Youths. Early adolescence is a crucial developmental milestone particularly with respect to peer relations and friendships. {Sullivan, 1953). Clinical research, in

fact, indicates that poor peer relations during this stage are predictive of mental health problems later in adolescence and in adulthood (Achenbach & Edelbrock, 1981). Boys as well as girls have an intense desire to

be accepted and valued by their peers, for which the skills of cooperation and compromise are barest essentials (Buhrmester & Furman, 1986). p. 131) . Peer groups are especially influential in persuading latency aged children to experience with drugs {Anderson, 1990,- Black, Feigelman, Li, & Stanton 1994). Freud defined (Walsh, 1990,

latency age, ages six to twelve, as the time in which children break from their parents and place energy into peer groups and social skills {Santrock, 1995). It is at this

time and through adolescence when children are extremely

88

vulnerable to peer pressure.

Children in groups will often

do things they would never do on their own (Adler, Irwin, Kegeles, Millstein, Tschann, & Turner, 1994; Santrock, 1995; Berdiansky, 1991) . Things such as delinquency are not uncommon (Albrecht & Rosella, 1993; Anderson, 1990; Arkin & Funkhouser 1990; Brown, 1990; Safyer, 1994; Santrock, 1995). This peer pressure can take many forms. One form in particular being experimentation and use of drugs (Arkin & Funkhouser, 1990). Prevention programs may provide children

with a positive peer group experience that is drug free (Vaughan & Willis, 1989). This may help children avoid

delinquency and become educated on drugs (U.S. Department of Education, 1992). Erikson states a six to eleven year old child is preceding through the stage of industry vs. inferiority. Children learn quickly and avidly during this stage of development. School is an essential force and children

apply themselves to tasks and persist in the work involved until a satisfactory completion point has been reached. Accomplishment and learning in school carries with it a sense of pride and pleasure (Santrock, 1995) . Yet, shifting from elementary to junior high school at this time presents

89

interpersonal, organizational and academic pressures (Walsh, 1990). In addition to school, Erikson states a child's

significant relations and future employment are formed through one's neighborhood. This is a time in which drug

trafficking may be considered a career choice among the urban youths who are exposed to drug involvement (Anderson, 1990; Black, Feigelman, Li, & Stanton, 1994). Thus, during

this stage of learning, public schools in urban areas attempt to train children for future employment and adjustment to their culture (Sabol, 1991). In most

cultures, including the array in urban neighborhoods, surviving requires the ability to work cooperatively with others (Bannasch, Chin, Chin, Cross, Palombo, & Palombo, 1980; Sabol, 1991; Safyer, 1994). Social skills are among

the important lessons taught in school and learned at this time (Bannasch, Chin, Chin, Cross, Palombo, & Palombo, 1980) . During latency, a child's character is not yet solidified or crystallized. It is in a germinal state which

enables new corrective experiences to be internalized (Santrock, 1995). By adolescence, an individual no longer

has the ability to respond in this manner because the

90

personality has rigidified.

Erikson states adolescence is

the stage of ego identity vs. role confusion, a time of experimentation and trying on different roles (Santrock, 1995). It is also a time of change and high stress which Children

may cause youths to be susceptible to drug use.

need to enter adolescence with a solid foundation of knowledge regarding drugs (Safyer, 1994}. Drug abuse prevention programs need to focus on youth before adolescence {Bailey, 1988; Greenwood, 1992,- Safyer, 1994 ; Sanchez, 1987) . Research suggests that the early adolescent years mark the beginning of a downward spiral for some individuals, a spiral that leads some adolescents to academic failure and school drop out (Eccles, Midgley, Wigfield, Buchanun, Reuman, Flanagan, & Maclver, 1993}. For example, Simmon and Blyth (1987) found a marked decline in early adolescents' school grades as they move into junior high school. Further more, the magnitude of this decline was predictive of school failure and drop out. Similarly

timed developmental declines have been documented for motivational constructs as interest in school (Epstein

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& Mcpartland, 1976); intrinsic motivation (Harter, 1981); self-concepts and self-perceptions (Eccles, Midgley, & Adler, 1984,- Harter, 1982; Simmons, Blyth, Van Cleave & Bush, 1979); and confidence in one's intellectual abilities, especially following failure (Parsons & Ruble, 1977) . There are also reports of

age-related increases during early adolescence in such negative motivational and behavioral factors as test anxiety (Hill, 1980), learned helplessness responses to failure (Rholes, Blackwell, Jordon, & Walters, 1980), focus oh self-evaluation rather than task mastery (Nicholls, 1980), truancy and school dropout (Rosenbaum, 1976; see Eccles et. al., 1984, for full review). Although these declines are not extreme there

is sufficient evidence of a gradual decline in various indicators of academic motivation-such as attention in class, school attendance, and self-perception-over the early adolescent years to make one wonder what is happening (see Eccles & Midgely, 1989, for review) (Eccles, Midgley, Wigfield, Buchanun, Reuman, Flanagan, & Maclver, 1993, p. 90).

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Early adolescence is also a time when a child seems to emulate the behavior of adults with whom they identify (Santrock, 1995). A child's modeling includes everything

about the adult, including their perceptions on drug use and abuse {U.S. Department on Education, 1992). A parent or

teacher can function as a role model, while educating on drug abuse (Benard, 1993; U.S. Department of Education, 1992). Children may emulate these messages. While studying

moral conduct and modeling behavior of the latency age child, Albert Bandura stated, "moral standards are usually modeled then eventually internalized" (Santrock, 1995).

Ellen Greengross Levine (1980), author in The Arts in Psychotherapy. writes regarding latency aged children. explains the traditional Freudian view of latency development to be a closing down of impulses and a moving towards abstract functioning. A latency age child has lived She

through the storm of Oedipal conflicts and is ready to put family romance aside, concentrating on getting things done (Levine, 1980) . She agrees with Erickson that this is a

time of full day school programs and learning. (Levine, 1980; Santrock, 1995). A child enters the school culture and begins to learn how to function around peers and apart from

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parents (Levine, 1980) . Levine (1980) describes latency as "a complicated internal process". She recalls Freud's view

of latency as a time for the ego and super ego to gather forces and to cement themselves more strongly (perhaps preparing for the onslaught of puberty). It is a time for a

child to practice new defenses, such as reaction formation and repression. With the emergence of these new defenses

necessary for consolidation of the ego, it has been suggested that free expression and free association dry up in this period of development (Levine, 1980) . Although researchers, such as Freud may believe six to twelve year old children lack free expression during this stage, Brittain & Lowenfeld (1987) writes about a child's creative growth during this stage of development (refer to Art Therapy section of Literature Review). Contrary to Freud,

Brittain & Lowenfeld (1987) felt a child's creativity was always growing, even during the latency period of development.

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DISCUSSION & CONCLUSIONS

Prior to conducting this research, I had hypothesized that art therapy could be beneficial when coupled with existing substance abuse prevention programs. This belief

was generated while using art therapy to complement an existing drug abuse prevention program. The program

targeted children from underserved urban areas in Philadelphia, Pennsylvania. As a result of this experience

I believe that children from urban areas are at greater risk for abusing drugs than children from other areas due to a variety of social ills. The literature reviewed supports this belief. {Anderson, 1990; Bailey, 1989; Brown, 1990; Greenwood, 1992; Schubiner, Scott, & Tzelepis, 1993,- Safyer, 1994). The

majority of urban children were afraid of their streets and even felt unsafe in their homes (Albrecht & Rosella, 1993; Anderson, 1990; Safyer, 1994). The researcher wondered if

drugs were used by these children as a defense against this fear. Peter Greenwood (1992) states that drugs are used to

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escape reality, and I concur.

I thought drugs helped urban

children learn to escape the chaos of their environment, serving as a coping mechanism. The researcher questioned if

art therapy could provide an alternative to drug use and if it could help in teaching life skills to help children survive living in an underserved urban community. I knew I

could not change where these children lived or the chaos each child internalized as a result of living in this environment, but perhaps I could change the way children acted out their fear. I wanted to offer an alternative way

children could express the chaos, instead of allowing it to be expressed through maladaptive behaviors such as substance abuse. After ending this short term prevention program, I continued working as an art therapist in an urban middle school in hopes of finding answers to questions such as, do urban children use drugs to escape the chaos of their environment? and if so, could art therapy offer these children an alternate way to express the chaos they internalize as a result of the social ills in an urban environment? I will often refer to these experiences

throughout my discussion to strengthen the readers

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understanding of the dynamics of latency aged children who live in an urban environment. I will discuss the advantages

and limitations to providing art therapy services in effort to prevent substance abuse among urban children. Also

proposed are art therapy techniques and prevention programming ideas which I believe will serve the purpose of offering concrete direction to art therapists who wish to utilize art therapy to enhance the effectiveness of substance abuse prevention programs. Lastly, I provide a

thorough review of why art therapy could be beneficial when coupled with existing substance abuse prevention programs and how/where to marry it into these programs. Research by Silver (1989), as well as Lowenfeld (1987) states art therapy has the ability to foster a child's learning. When coupled with an education on drug abuse art

therapy can increase the recall of this information and promote an understanding of abstract concepts such as the long term effects of gateway drug abuse. Art therapy can

teach a child life skills such as problem solving (Auly, 1986; Fuson & Gordon, 1989; Golomb, 1992; Lusebrink, 1990; Markus, 1988; Silver, 1989), assertiveness training (Silver, 1989), stress reduction (Moore, 1983; Silver, 1989),

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responsible decision making (Franklin, 1992; Moore, 1983,Rubin, 1984; Silver, 1989), coping skills (Silver, 1989), socialization (Brittain & Lowenfeld, 1987; Case, 1948; Julliard, 1994), peer resistance skills, and self control/empowerment (Julliard, 1994; Moore, 1983; Silver, 1989). Research supports the belief that these life skills

may strengthen a child's defenses resulting in possible prevention of drug use. Art therapy can help build a

child's self-esteem while providing an alternate form of communication {Bloomgarden & Kaplan, 1993; Brittain & Lowenfeld, 1987; Julliard, 1994; Lusebrink, 1990; Moore, 1983; Rubin, 1984; Silver, 1989). As a result, a child may

develop a stronger ego which functions to resist drug experimentation. Art therapy teaches children to express

feelings safely and increase self awareness, thus fostering affective development (Brittain & Lowenfeld, 1987; Johnson, 1990; Julliard, 1994). It appears that teaching a child to

express feelings such as fear and anger will aid in reducing the bound frustrations urban children experience as a result of their environment. This in turn could decrease a child's

vulnerability to drug abuse.

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Moreover, it appears that art therapy could be beneficial in enhancing substance abuse programs because of its inherent nature to stimulate our senses. Art stimulates

the mind and body, as do drugs (Johnson, 1990) . Art therapy can be an alternative to substance abuse because it taps into the artists senses (Brittain & Lowenfeld, 1987; Silver, 1989) and often creates the physical and emotional energy (Wadeson, 1980) many drug users seek. natural "high". Art therapy can be a

It can also function as a defense mechanism

for the children who may turn to abusing drugs as a means for coping with the chronic stress of urban living (Albrecht & Rosella, 1993; Black, Feigelman, Li, & Stanton, 1994; Danish, Farrell, & Howard, 1992; Safyer, 1994). Art therapy

can be utilized as an alternative to substance use by satiating a drug user's need for stimulation (Johnson, 1990). Instead of seeking stimulation through drug use, an

individual could learn to seek stimulation through art use. Thus, art therapy could decrease a child's vulnerability to using gateway drugs. Yet, Johnson (1990) wonders how

creativity can be an antidote to substance use when so many creative artists become addicts, i.e., James Joyce, Eugene O'Neill, Alvin Ailey. Moreover, Johnson (1990) argues that

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creative artists have often used stimulants to help access inner images, as well as sedatives to numb the intensity of their psychic visions. According to the multicomponent comprehensive approach to prevention programming suggested by the U.S. Department Of Health and Human Services, a substance abuse intervention program should be incorporated into multiple systems such as school, community activities and (if possible) family affairs. The U.S. Department of Health and Human Services

also tends to agree with prevention experts that gateway drugs should be targeted in a prevention program. Delaying

or preventing the initiation of gateway drugs is important in its own right and as a potential strategy for preventing use of harder drugs (Bell, Ellickson, & Hays, 1992). This

approach can provide two interventions for the price and effort of one. To successfully prevent substance abuse, programs need to begin targeting children at approximately age six. Anderson (1990) states and I concur that children in urban communities are engaging in high risk behavior at an early age. By age twelve many have had sexual intercourse and are

smoking blunts (refer to Drug Abuse section of the

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Literature Review).

This realization lead me to focus on

latency aged children when offering suggestions for an early intervention program. As discussed, ages six to twelve is a time children enjoy learning and are open to new ideas (Santrock, 1995) such as the effects of drugs. Moreover, a latency aged

child will soon become an adolescent--a time when many youngsters often experiment with drugs and become set in patterns of use (Bernard, 1993) . Arkin and Funkhouser (1990) also believe that programs need to intervene prior to adolescence, the stage when drug use often proceeds to substance abuse and addiction. In addition, adolescence is

a time of breaking from parents, trying on roles, and searching for an identity (Santrock, 1995). Children may

rebel from their parents by using drugs or search for their identity through experimenting with different highs. Adolescence puts a child at high risk for involvement in drug use. This makes latency, the stage prior to

adolescence, a good time to target children in drug prevention efforts. Research indicates, those children with a drug free support system are less inclined to use drugs (Vaughan &

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Willis, 1989)

Unfortunately, many urban children grow up

without a support system which according to research, puts them at risk for becoming involved with drugs (Baer, Caid, McKelvey, Mclaughlin, & Webb, 1991). In my practice, I have observed children with one or more supportive parents to be competent at expressing their feelings. They also appear to

practice healthier coping skills than the children who lack parental support. Therefore, I concur with Vaughan & Wills

(1989) that those children with a support system are better equipped with life skills. Monye and Oyemade (1990) and

Vaughan and Wills (1989) state that increasing a child's social support to be indicative of strengthening their life skills. use. This in turn increases a child's resistance to drug

Research has indicated, children without support

systems may be prone to abusing gateway drugs {Monye & Oyemade, 1990). My experience agrees with Anderson (1990)

that it is commonly the children who lack support that want to remain in their community to become successful drug dealers. When observing this pattern I began to wonder if

children who lack a supportive parent or social support system often resort to coping via drug use.

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These children, who are lacking support, often attempt to search out role models and social support through their school. Unfortunately, I have observed what Mishne (1993)

stated, that urban classrooms are over crowded and often school staff members are burned out. This leaves children

little, if no chance of bonding with a teacher or staff member who could function as a role model. A team of mental

health professionals offering an early intervention program could provide positive guidance and support to these children in urban communities. The literature reviewed indicates that underserved urban areas are in need of prevention programming due to social ills (Anderson, 1990; Benard, 1993; Clayton & Leukefeld, 1995; Crayton, Pickens, & Scott, 1987; 1990; Goplerud, 1991; Hansen, 1993; Safyer, 1994) Moreover,

living in an economically depressed area, such as many urban communities increases a child's vulnerability to drugs (Arkin & Funkhouser, 1990; Goplerud, 1991). This reality

led me to offer art therapy services in an underserved urban community. Serving as an art therapist and prevention

coordinator in an urban environment has been challenging, and at times difficult. Many of the behavioral problems

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which exist in urban areas, including drug use, appear to be a result of environmental stimuli (Anderson, 1990). Through

experience I noticed when a child's environment was altered, often a behavioral change occurred. While in the atmosphere

of my art therapy group, children labeled with behavioral problems were often well mannered and referred to my room as the "safety zone". After observing a pattern of good

behavior via the labeled children, I concluded many of the behavioral problems I observed had been environmentally induced (Albrecht & Rosella, 1993; Safyer, 1994). Mental

health professionals can not change the environment in which these children live in to a safety zone, it is often difficult to work under these limitations. Changes in a

child's behavior can be observed in a safe and isolated group environment yet, they are spurious. When returning to

the chaos of urban surroundings children commonly resume acting out behaviors, such as drug use. Yet, art can function to temporarily relieve the stress imposed by this environmental stimuli. Art therapy offers

children the opportunity to act out frustrations on their environment through use of art materials while simultaneously maintaining control (Brittain & Lowenfeld,

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1987; Naumburg, 1966; Rubin, 1984; Silver, 1989; Wadeson, 1980). Plasticine clay and acrylic paints are common

materials utilized to provide a child an outlet for their energies. A task used to achieve this same goal is the This is an art project rendered by all Large mural paper is used by Commonly,

community mural.

group members simultaneously.

the group to draw a community of their choice.

children become aggressive, venting frustrations safely on the environment they have created. In their urban

neighborhood they are helpless against the social ills yet, in art therapy they experience control over people and events (Kramer, 1958; Naumburg, 1966; Rubin, 1984; Silver, 1989; Wadeson, 1980) . Also, as in any art therapy task, creating a community mural provides children with an increase in physical and emotional energy (Wadeson, 1980). When working on this task in acrylic paint with three middle school urban children, their body movements became energized. They dove into the paint with their hands and

created a tornado which destroyed the middle school they had initially painted on the mural paper. The children gave

their mural a funeral service then shared their wish to repeat the process the following week. This session offered

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the children an opportunity to be powerful thus, changing their painful experiences and fears into a pleasant and empowering event (Bloomgarden & Kaplan, 1993,- Franklin, 1992; Kramer, 1958; Lusebrink, 1990; Naumburg, 1966; Rubin, 1984; Silver, 1989; Wadeson, 1980). The art process lowered

their defenses (Wadeson, 1980), thereby regressing their behavior, which in turn reduced their inhibitions allowing the expression of anger at their community. The children

projected their feelings onto the drawing, stating the tornado had to destroy the school. This objectification

{Wadeson, 1980) allowed them to express their anger safely at a distance. The tornado was destroying the school and An entire story

people were fleeing or caught in the storm.

about destruction, chaos and fear was being told through one isolated image. Wadeson (1980) calls this spatial matrix.

Only an image has the ability to communicate numerous interactions simultaneously. When looking at the image I The image portrayed a

had an intense affectual response.

powerful rendition of urban chaos which could not have been adequately communicated through verbal language (Wadeson, 1980). The children may not have had the words to express

their anger or perhaps they were afraid to admit these

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frightening feelings.

In either event, this mural existed

as a permanent record (Wadeson, 1980) of the children's thoughts and feelings and was used in future sessions. Often this mural was retrieved during discussions on fear and violence in their community. I believe this mural to be

an excellent example of how the art process offers a healthy means to vent frustrations and cope with stress instead of numbing fears via drug use. Guided imagery techniques can also be used as a means to teach the daily coping skills needed to handle the environmental stressors imposed on children. Bloomgarden

and Kaplan (1993) taught stress reduction by promoting relaxation through guided imagery. Commonly, this technique

involves a descriptive story which elicits mental images in group members. After the story, group participants are

asked to render the image which was evoked through the telling of the story. These stories often produce a As

hypnotic trance which functions to relax an individual. a result, children may not need drug use to numb psychic pain and internal chaos.

Guided imagery offers children the

opportunity to learn skills necessary for coping with the chronic stressors of urban living. Moreover, these skills

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may aid in handling stress associated with the transition from elementary school to middle school and puberty (Adler, Irwin, Kegeles, Millstein, Tschann, & Turner, 1992). These children also focus on peer groups and are vulnerable to peer pressure (Santrock, 1995). Art therapy Social

can offer children a peer group which is drug free.

skills can be taught through group art therapy which help foster a child's ego strength (Bannasch, Chin, Chin, Cross, Palombo, & Palombo, 1980; Brittain & Lowenfeld, 1987; Case, 1948; Julliard, 1994; Walsh, 1990), this in turn may improve a child's self concept and desire to resist drugs. A peer

group can also be used to challenge a common childhood belief that gateway drug use is acceptable among minors {normalized belief). Group members can reveal and compare

personal attitudes and behaviors about alcohol and drug use. Perceptions about the prevalence and acceptability of gateway drug abuse can be addressed. The art therapist can form dyads according to the children's patterns and perceptions on gateway drug use. Children should be matched according to contrary beliefs i.e., normalized beliefs vs. reality based beliefs. Members, in the dyad can be asked to draw how your partner

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feels about people their age drinking.

When the drawings

are completed, partners can trade and test the reality and accuracy of their partners perceptions. Group members can

also be asked to draw the role alcohol and drugs play in your family or group of friends. Goplerud (1991) states, and I concur that many children view the use of gateway drugs among minors as normal or appropriate. Often these normalized beliefs stem from the The media

impact of advertising on our communities.

promotes smoking and drinking as glamorous {Bernard, 1993; Goplerud, 1991). Children can search through magazines to

find such images, then reconstruct the advertisement to promote healthy behavior. For example, a woman engaged in This

smoking can be redrawn eating an apple or dancing.

illustrates alternatives to smoking, a successful strategy used by prevention experts {Bernard, 1993). Children can

also chose to redraw the health compromising behavior along with its short or long term effects. Both the magazine

clipping and the new rendering of the magazine advertisement can be hung side by side. The image (Wadeson, 1980) may

impact its audience, teaching the negative effects of drugs and simultaneously increasing ones memory (Brittain &

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Lowenfeld, 1987; Kramer, 1958; Rubin, 1984; Silver, 1989). This task is one way to promote healthy alternatives to drug use, educate on the media's influence, and increase a child's self-esteem. Therefore, possibly strengthening a A confident child may

child's ego and decreasing drug use.

not need drug use as a crutch to "feel good". Research indicates, teaching problem solving skills is effective in preventing drug abuse (Benard, 1993; Silver, 1989; Donaldson, Graham, & Hansen, 1993). These skills can

be promoted in art therapy thus, children may be better equipped to handle peer pressure to use drugs. An art

therapist can teach problem solving by emphasizing a child's power to make decisions and by presenting a task to cultivate problem solving skills (Auly, 1986,- Franklin, 1992; Fuson & Gordon, 1989,- Golomb, 1992; Lusebrink, 1990; Markus, 1988; Silver, 1989). An art therapy problem solving task can be created in comic strip form. A paper can be divided in half, the first

square containing a picture of a child being offered marijuana and the second square remaining blank. The first

square provides the child with a problem and the second leaves room for the problem to be solved through the

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rendering of an image.

After completion of this art task, Children

solutions to the presenting problem can be shared.

will have different solutions, illustrating each child has several options if confronted with this problem. When

conducting this task, I emphasized responsible decision making as the children drew and practiced their problem solving skills. Problem solving skills may be acquired "An artist must

throughout the process of this art task.

make choices, weigh alternatives, criticize, and act on his decisions in order to create an art work or indeed make anything at all" (Carnes, 1979, p. 74). The choices a child makes throughout this problem solving task can be brought to their attention to build self-esteem and empower the child's desire to learn responsible problem solving. Silver (1989)

and Franklin (1992) believe, skills learned in art therapy, such as problem solving can be transferred to other areas of a child's life. In my experience, this has been difficult to accomplish with children returning to an environment which reinforces fighting and drug use. Children need to be educated on how to become assertive in a responsible manner. This may help children want to This ego strengthening skill

resist using gateway drugs.

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increases the probability of deterring experimentation of substances and reducing overall susceptibility to peer pressure (Greenwood, 1992). The art therapist can encourage

assertiveness solely between group members or between group members and the art media. Persistence can be taught and appropriately role modeled by the art therapist. If a child becomes

frustrated, problem solving and persistence should be encouraged by the art therapist. Offering an art therapy

task provides children many opportunities to assert themselves. A child can create plasticine figures or

puppets and role play assertiveness skills with other group members. When children learn not to give up during an art

therapy task, they may have developed a skill necessary in resisting peer pressure to use drugs. Art therapy can help increase a child's self-esteem which may lead to personal empowerment and the delay or prevention of gateway drug use. Often children turn towards I

using drugs because they suffer from a low self-esteem.

have noted through my experience, using drugs can often make these children feel accepted, "cool", and grown up. art therapy is used to promote a child's self-esteem When

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confidence may increase thus, a child's desire to use drugs to feel cool or accepted may decrease. I believe an art

therapist should emphasis each child's individuality and validate their uniqueness through their art work and behavior. Engaging a child in an art task that uses their fingerprints or hand prints promotes their individuality. Children can be told their fingerprints/hand prints are like non other, each being special in its own way. Art tasks

which are easily mastered also promote ego strength and increase self-esteem. Moreover, promoting a healthy body Children can

image can increase feelings of self worth.

create a life size shadow drawings of their "healthy self" while simultaneously learning the location of organs in the body and the effect drug abuse has on them. Children can

render drawings depicting themselves engaged in healthy behaviors, i.e., exercising, healthy eating. As stated, research seems to indicate that creating images in conjunction with an education on substance abuse will increase recall of information (Brittain & Lowenfeld, 1987; Lusebrink, 1990; Markus, 1988; Silver, 1989). It is

my suggestion that while educating on gateway drugs the art

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therapist should have children periodically do a free drawing about what they have learned from the program. If

children need more structure, the art therapist can ask for a healthy vs. unhealthy drawing. The paper can be folded in

half with one side depicting a healthy image and the other side depicting an unhealthy image. The images produced will

reflect the parts of the program which have successfully educated the children and which have not. This is an

excellent way to assess the effectiveness of your program. In my practice, a free drawing was completed by a ten year old boy which showed a figure with a large grotesque yellow mouth and a black chest. drawing was agitated and bold. The line quality in this This boy stated he did not The majority

want to, "get yellow teeth and black lungs".

of the free pictures produced during this week reflected the children were internalizing the demonstrations and education I provided on smoking. Many of the pictures reflect a

knowledge of the short term vs. the long term effects of drugs. This is due to the difficulty a child's has in

facilitating abstract thinking during the latency period of development (Santrock, 1995).

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As stated, art can be used to help children organize and understand abstract concepts (Brittain & Lowenfeld, 1987; Silver, 1989) such as, the long term effects of drug abuse. Often children feel as though drugs can't effect A cause and effect drawing can be done to

them long term.

help children understand they are not immune to the consequences of drug abuse. Older latency aged children who

can facilitate abstract thought, can be asked to draw themselves in the future. This task can promote a child's

awareness of the effects a gateway drug has on their mind and/or their body. As a result, a child may come to

understand, if they use this drug, then this will happen. This art task teaches predictability and may help minimize or delay drug use. The art therapist can even blend a Children can

demonstration with a cause and effect drawing.

be given a thin stirring straw and a fatter drinking straw. They can be asked to inhale through the thick straw first, then the thin stirring straw. Children will notice the This can

smaller straw takes more lung capacity to inhale.

be compared to years of smoking and the damage it causes to your lungs. Afterwards, a cause and effect drawing In my experience,

pertaining to smoking can be rendered.

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drawings were rich in communicating the effects smoking has on your breathing. This demonstration stimulated the

children's senses (Brittain & Lowenfeld, 1987,- Silver, 1989). As a result, their drawing experience was

intensified thus, I believe learning was intensified. Drug education is more readily internalized when complementing an informational component with activities involving the senses, such as art therapy. As stated,

research shows, the more senses involved when learning the better a child's recall (Brittain & Lowenfeld, 1987; Silver, 1989). Art offers stimulation of the senses. Bright

colored paints can be used for visual stimulation and scented markers or clay for olfactory stimulation. Tactile

stimulation can be promoted through utilizing materials such as coarse or furry fabrics. Auditory stimulation occurs

when a child creates sounds with art media during the art process, i.e., banging of clay on a table.

My work seems to concur with Silver's (1989) that latency aged children may not have the words to speak about the effects of drug abuse, but they can create images to communicate such messages. These messages can teach others

and remind the child of what was learned throughout their

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education on substance abuse.

A drawing tends to

communicate honest beliefs, such as a child's perception on gateway drug abuse. It is easy for a child to verbally

repeat informational material on the dangers of substance abuse. Does the child believe what he or she is saying? It can A

drawing can give an art therapist the true answer.

function as a means to objectify (Brittain & Lowenfeld, 1987; Naumburg, 1966; Silver, 1989; Wadeson, 1980) a child's feelings and help recognize their beliefs. Art work is a

concrete indicator of a child's thoughts, feelings and perceptions on gateway drug abuse. Benard (1993) states and I concur that a team approach should be taken when providing prevention services. Individuals may come from different professional backgrounds and psychological orientations thus, each having something unique to offer a program. I have worked as a part of a They were well

team with students in the field of medicine.

equipped with knowledge pertaining to physical medicine, where as I had an understanding of psychological issues. I

found this to be a good balance when teaching the children about drug abuse. The children's questions, whether they

pertained to physiological or psychological issues could

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always be answered.

Moreover, through my experience I have

learned that working by oneself as a mental health clinician puts restriction on ones ability to meet a child's needs. One person has only so much time to dedicate. It is easy to

spread yourself too thin, which can result in an ineffective program. Another limitation to be aware of when providing art therapy services through a school system is the possible restriction of conducting "therapy" in an educational setting. It is "legal to provide support to children and

conduct psychoeducational groups but...therapy in this setting can be considered unlawful. When working in a

public urban school system I was permitted to conduct support groups, but not offer therapy to the children. This

restriction made providing art therapy services difficult because support groups and therapy groups are virtually one in the same. As long as I referred to my sessions as

providing support and not therapy, the school system considered me to be working in congruence with the law. Meeting with the children on a regular basis, resulted in the development of intimate therapeutic relationships which I believe was inevitable. When a child trusts, he/she

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discloses personal information and many school systems consider this disclosure a result of therapy. Therefore,

because children eventually trusted and disclosed personal information to me, I was considered by the school district to be providing therapy, which is interpreted as unlawful by this particular educational institution. This resulted in

the termination of the art therapy program I had operated. I found, working with children individually puts an art therapist at risk for this to occur more so than offering only group sessions. This is because the individual

therapeutic relationship is not diffused by the group process and multiple objects, rather it is intensified by the intimate nature of a one to one session. A note of

caution--one of the pitfalls of working in an urban school is that the system fights any change. A practitioner

working in an urban school needs to be aware of this limitation. This reality seems to suggest that children in

urban areas are undervalued. Janet Bush (1995), ATR has implemented art therapy into the Miami, Florida school system. The state laws in Florida

for providing therapy services in an educational setting are less restrictive than in Pennsylvania yet, she has still had

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to overcome many obstacles in accomplishing this integration. Bush (1995) collaborates with teachers,

parents, and school personnel about children's learning, social and behavior problems. She helps others better

understand child development and it's relationship to learning and behavior. She works towards strengthening

relationships between educators, parents, and the community. She provides educational programs on classroom management strategies, parenting skills, working with special need students, teaching and learning strategies, using art as informal assessment in the classroom, and child development and art. She evaluates the effectiveness of programming and

conducts research to generate new knowledge to improve children's learning and behavior. While working closely

with parents and teachers, Bush (1990) evaluates cognitive and emotional development of children, academic strengths and weaknesses of children, school and classroom programs, and the personality development of children. Bush (1995)

has proven art therapy can be used effectively in public schools. Therefore, I believe art therapy can successfully

offered in the public urban school system to help decrease a child's vulnerability to drug use. After all, school is the

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most logical place to offer children an early intervention program. A fall back in providing art therapy services in the urban community is the possibility of burn out due to the intensity of need which stems from a lack of social support services (Anderson, 1990; Mishne, 1993) . When working in this community I became overwhelmed by the depth of need, via children and staff alike. I learned it is important to

be aware of ones own limitations and to set clear limits with not only the children, but also with the staff. Working as a part of an underserved urban community can be engulfing and this can be easily internalized by the art therapist resulting in high levels of anxiety (Anderson, 1990; Mishne, 1993). An individual must be aware of this

prior to working in this setting to reduce possibility of burn out due to vicarious traumatization. A program should provide proper closure to maintain the emotional well being of the children and the therapist. way to accomplish this is by hanging the art products created throughout the program in a "gallery". The children One

can plan a reception to show off their art work and family and friends can be invited. This offers children the

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opportunity to educate others on what they have learned, which in turn increases their recall of information. Moreover, this closure activity provides children with a sense of pride which fosters their self-esteem. Substance abuse prevention programs are important in future health care planning (O'Neill, 1995; Healton & Novotny, 1995). A mental health professional needs to be I

flexible and accommodating to the changes in health care. believe the prevention health care model needs to be

thoroughly investigated by all health care professionals as a means to prevent substance abuse disorders among latency aged children from urban areas. Longitudinal studies which

track children past the stage of adolescence need to be conducted to test the framework of my ideas and the effectiveness of a program. Short term studies are also

needed, although drug use patterns are difficult to measure due to the length of these studies. Programs can be evaluated through teacher reports which can track a student's display of maladaptive behavior and degree of success and effort in school. A child's

attendance records and grades could be recorded. Questionnaires and drawing assessments can be completed by

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children twice a year to track their pattern of drug use and experimentation with various substances. The drawings will

reflect a child's unconscious thus, offer permanent and concrete evidence of the program's effectiveness (Wadeson, 1980). School guidance counselors can keep a log on each Visits to

child involved in the early intervention program.

the school guidance center can be dated and documented, as well as information obtained from peers regarding fellow student's behavior and drug use. Often student peers are

the best resource for tracking a child's development and drug involvement. The school nurse can also keep records of A student's physiological and

these student's complaints.

psychosomatic illnesses can offer insight to their overall health and development. Proposed research studies would involve two groups. The first group would offer an early intervention program utilizing art therapy to prevent or delay gateway drug abuse, among latency aged, urban children. This group would

blend a non verbal, art therapy approach to an existing substance abuse prevention program. The second group, being

a control group, would focus on a verbal approach to the early intervention of gateway drug abuse, among latency

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aged, urban children.

This group would be conducting the

same existing substance abuse prevention program from group one, minus the art therapy. Students would be selected from

a random sampling and the results of each group will be compared and evaluated. To successfully compare the results

of each group, a standard scale for measurement could be developed. This will aid in conducting a valid evaluation

of the study. Another research study to be conducted would be the comparison of non verbal modalities in the early intervention of gateway drug abuse among latency aged urban children. Movement therapy, music therapy, and art therapy Each creative

will be three groups in the proposed study.

arts modality will be coupled with the same existing drug abuse prevention program. The goals of the groups will be

the same, only the means to achieve these goals will differ by modality. Students will be selected through a random Random

sampling in effort to avoid bias to a modality.

sampling will also avoid ones desire to pair children with their modality of choice, which inevitably may effect the results of the study. A scale could be developed and

utilized to test the validity of the study.

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I suggest to not limit the program by a specific orientation or professional background. I have had a

successful experience with a psychesoma approach yet, I believe each mental health professional to be beneficial to a program of this sort. A social worker may be more

familiar with environmental influences effecting a child, while a movement therapist may have more insight to street wise etiquette by observing a child's movements. Both

perspectives are important when addressing this population in an early intervention program targeting gateway drug abuse. My suggestion is not to limit a team, but rather to

expand it through employing a variety of health professionals and integrating personal approaches, theories, and orientations. No one sets out to be addicted...Despite numerous attempts to combat drug abuse more than fifty percent of Americans under age thirty five have tried illicit drugs at some point in their lives. The vast majority

of these drug users will never become addicted. However, the first hit of weed launches others on a self destructive trajectory from use to abuse to addiction. For them, the titillation of

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experimentation and the search for some way to cope with life lead to the degradation of a habit out of control. As one addicted fourteen year old screamed "I have to quit, I have to quit.

into the internet:

That's what I say to myself but it just never happens." (Livingstone & Stern, 1996, p. 1).

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SUMMARY & CONCLUSIONS

Cities are often a prison...schools, with barred windows and high fences, resemble jails...lots filled with garbage and rats are often the children's only playgrounds-if drug dealers have not taken over first (Sabol, 1991). Impoverished urban neighborhoods generate chronic levels of stress for today's inner city youth thus, putting these children at risk for substance abuse (Safyer, 1994). Due to

living with incredible daily violence and a lack of support, many urban youth find some relief from environmental stress by engaging in substance abuse (Safyer, 1994). Art therapy, when coupled with existing gateway drug abuse prevention programs, can offer these children a chance to avoid the emotional pain caused by chemical addiction and gateway drug abuse. An art therapy approach to the early

intervention of gateway drug abuse will strengthen a child's ability to resist drug use by promoting responsible decision making, socialization, assertiveness training and healthy coping strategies. Acquisition of these skills, along with

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others cited in the Literature Review may, decrease a child's vulnerability to drug use and increase ego strength. Moreover, art therapy offers an alternate means of communication which further enforces verbal messages taught during a substance abuse program. Art inherently involves

the senses which increases a child's recall and potential for learning about drug abuse (Brittain & Lowenfeld, 1987; Silver, 1989) . Arousal of these senses stimulate a child and open doors of perception (Johnson, 1990). Unlike drug

highs, art therapy can provide a natural high serving as an alternative to drug use. The author believes art therapy to be effective in reducing an urban child's vulnerability to gateway drug abuse while simultaneously preventing chemical addiction. When coupled with an existing gateway drug abuse prevention program, art therapy enhances a child's life skills, serves as an alternative to drug use, and increases a child's recall of information regarding drug abuse.

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