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Address correspondence to Roger E. Thomas, MD, PhD, Department of Family Medicine, University of Calgary, G012, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada.
Use of alcohol and illicit drugs by adolescents is an important problem worldwide.
Objective
To undertake a systematic review of mentoring in preventing/reducing adolescents' alcohol and drug use.
Data Sources
We searched 8 multidisciplinary electronic databases, the gray literature, and reference lists of included studies.
Study Eligibility Criteria, Participants, and Interventions
Randomized controlled trials (RCTs) of mentoring in adolescents to prevent/reduce alcohol or drug use.
Results
Six RCTs were included in this review. Four RCTs provided evidence on mentoring and alcohol use. The 2 that could be pooled showed less alcohol use by mentored youth. Six RCTs on mentoring and drug use were identified, 2 of which provided some evidence of the effect of mentoring in reducing drug use.
Limitations
Only 1 RCT was at low risk of bias for randomization. None of the studies stated they concealed allocation. Of the 6 included studies, 1 was at high risk and 5 at unclear risk for attrition.
Conclusions and Implications of Key Findings
Four RCTs provided evidence on mentoring and alcohol use, and the 2 that could be pooled showed less use by mentored youth. The 6 RCTs that provided evidence on drug use could not be pooled. Two did provide some evidence that mentoring is associated with less drug use. Very few well-designed studies evaluate the effects of mentoring on adolescent drug and alcohol use.
This updates a Cochrane Collaboration review on mentoring to prevent or reduce alcohol and drug use in adolescents. Two randomized controlled trials have been added to this updated review, while 2 other studies, previously included but not meeting current study criteria, have been deleted. Four studies assessed mentoring and alcohol; the 2 pooled found less alcohol use. Six assessed mentoring and drug use, and 2 found less use.
The 2011 United Nations world drug report estimates that 149–271 million people 15 to 64 years of age (3.3% to 6.1% of the world's population) used an illicit drug at least once in 2009.
Among these are 124–203 million cannabis users (22–59 million in Africa, 41–43 million in the Americas, 31–68 million in Asia, and 29 million in Europe); 12–21 million opioid users (1–3 million in Africa, 1–2 million in the Americas, 6–12 million in Asia, and 3–3.5 million in Europe), 14–20.5 million cocaine users (1–4 million in Africa, 8–8.5 million in the Americas, up to 2 million in Asia, and 4–5 million in Europe), and 14–56 million amphetamine users.
As a result of incomplete information, this report did not include estimates on the use of ecstasy, hallucinogenic drugs, inhalants, or nonmedical uses of benzodiazepines or anabolic steroids, and so likely underestimates the extent of drug use worldwide. Degenhardt and Hall
provide low, middle, and high estimates of the annual mortality attributable to drugs: the middle estimate for drugs is 197,000 and for alcohol 1,804,000 individuals worldwide.
Rates of alcohol and drug use among adolescents and young adults are substantial.
The 2004–2005 European Drug Addiction Prevention trial (EU-DAP) included 6359 students 12 to 14 years of age in 6 European countries. Of these, 24% had been drunk and 8.2% had used cannabis in their lifetime; 6.7% reported at least 1 episode of drunkenness, and 3.2% had used cannabis once in the past 30 days.
The 2001 US National Household survey reported that 60.5% of 55,561 surveyed consumed alcohol, with DSM-IV-defined rates of “tolerance” and “time spent obtaining alcohol, drinking, or getting over its effects” highest for the 18- to 23-year-olds, followed by those 12 to 17 years old. Individuals aged >50 years reported the lowest rates overall.
For DSM-IV tolerance and dependence symptoms, 7.1% of boys and 7.2% of girls aged 12 to 17 had tolerance symptoms; 1.2% of boys and girls had withdrawal symptoms; 5.4% of boys and 6.0% of girls used “much time” to acquire alcohol; and 3.2% of boys and 3.0% of girls reported episodes of hazardous use.
Cochrane systematic reviews have assessed interventions in schools, the community, families, youth clubs, colleges, emergency rooms, and young offender institutions to prevent alcohol use.
reported 20 studies of parenting programs, none of which focused on mentoring.) This review updates the Cochrane review of mentoring to prevent/reduce drug and alcohol use in youth.
Eight electronic peer reviewed databases (CINAHL, the Cochrane Library, Embase, Eric, Medline, PsycINFO, Social Sciences Abstracts, Sociological Abstracts), and ClinicalTrials.gov were searched through January 2013 (Fig. 1). The reference lists of included studies were scanned to identify additional studies of relevance to this review. Search criteria for Medline are listed in Figure 2. Experts in addictions and mentoring were consulted to identify additional studies relevant to this review. No language or date restrictions were applied.
The Mentor Organization provides the simplest and most inclusive definition of youth mentoring: “A personal relationship in which a caring individual provides consistent companionship, support, and guidance aimed at developing the competence and character of a child or adolescent.”
We operationalized the Mentor Organization mentoring definition thus: children (age 6 to 12) or adolescents (age 13 to 18), mentor (peer or adult), relationship (consistent, companionship, support, and guidance), and alcohol or drug use outcome data.
Study Appraisal and Synthesis Methods
Two reviewers independently assessed each abstract and full-text study for inclusion in this review. Inclusion criteria were: 1) study design was a randomized controlled trial (RCT) or cluster randomized controlled trial (C-RCT); 2) the study reported on the results of a mentoring intervention targeted at children (age 6 to 12) or adolescents (age 13 to 18); and 3) alcohol or drug use data were reported. In addition, studies were included if they reported on any of these primary outcome measures of interest: abstinence (never uses drugs and/or alcohol); number of individuals using alcohol or drugs at least once monthly; or reductions in alcohol or drug consumption. Two reviewers independently extracted data (using the longest available follow-up) into the Cochrane Alcohol and Drugs Review Group data checklist. Risk of bias was assessed by Cochrane Handbook criteria.
Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. Ver 5.1.0. Cochrane Collaboration; 2011. Available at: http://www.cochrane-handbook.org/. Accessed June 7, 2013.
In cases of uncertainty, we contacted authors for clarification. We excluded both studies on counseling interventions and interventions to improve parent–child relationships.
We planned separate analyses for RCTs that compared an intervention to a control group and those that compared 2 interventions. Because studies of alcohol and drug use by children and adolescents have varying outcome measures (monthly, weekly, or daily frequency, amount drunk or drugs ingested, or an index) we planned to meta-analyze RCTs if participants, interventions, and outcome measures were sufficiently similar to make pooling appropriate, and if heterogeneity as measured by I2 was <50%. Where comparable outcome measures were not available, we planned to dichotomize baseline never-users into never/began to use, and users into declined/unchanged or increased. We planned to explore clinical heterogeneity (differences in participants, interventions, and outcomes) and methodological heterogeneity (study design, risk of bias) if there were sufficient studies. The review protocol was registered with the Cochrane Drugs and Alcohol Review Group.
Results
Literature Search
A total of 2972 abstracts were screened; of these, 235 full-text articles were assessed and 6 RCTs included in the review (Fig. 3).
in a 2000 C-RCT recruited ten 6th grade classes in 10 middle schools in Springfield, Massachusetts, and randomized them to 1 of 3 groups: 1) mentoring by community adults, a community service activity (visiting frail seniors in nursing homes), and a 27-lesson school-based Positive Youth Development Curriculum (PYDC), which teaches life skills; 2) the community service activity and the PYDC; or 3) no intervention. Two cohorts of 6th graders (1997 and 1998) were each followed for 1 year.
Table 1Description of Included Studies and Results
High-risk students from ten 6th grade classrooms in 3 schools (n = 358)
Total study duration 16 mo; pretest beginning of school year; posttest end of school year; follow-up 6 mo later
Across Ages Program to reduce adolescent drug use. Mentoring Group: (1) mentoring from an elder, and adolescents help older adults (55+) maintain active roles, (2) PYDC: health and substance abuse information, community service. Curriculum Group: PYDC: health and substance abuse information, community service. Control group: no intervention
Problem behavior and knowledge of/attitudes toward ATOD Use (Center for Substance Abuse Prevention National Youth Survey)
Difference from pretest to follow-up: for alcohol: mentor = 1.28, curriculum = 1.33, control = 1.37; for marijuana: mentor = 1.10, curriculum = 1.18, control = 1.30, 1-tailed t tests for difference: mentor vs control = −1.87*, curriculum vs control = −1.29, control vs mentor = 0.72, mentor vs control comparison significant
Total study duration 6 mo; evaluation at completion of the 6-mo intervention
Substance use treatment and mentoring group: rapport building and goal setting, social stability, reinforcers (recreational activities and support systems); substance use treatment only group; no control group
Tobacco use (tool not specified); drug and alcohol use (Form 90, NI on Alcohol Abuse and Alcoholism); problem consequences of drug use (Problem Oriented Screening Instrument)
E-mail from Dr Bartle-Haring (January 15, 2012): Results noted for 28 youth at 6-mo evaluation: “Number of mentoring sessions nonsignificant in predicting the variation in the slopes for drug use, alcohol use, and tobacco use . . . age did not matter for either the intercepts or slopes”
Students (aged 14 y) from 28 schools—with self-reported need for additional adult contact (n = 128)
Total study duration 12 mo; average follow-up at completion of intervention: intervention = 396 d, control = 400 d
Mentoring group: participants recruited to Swedish branch of Mentoring Foundation: health promotion and prevention of drug abuse. Mentors trained for 2 d and pairs chose own activities. Control group: Research staff phoned 6 times to ask about perceived frequency and quality of contacts with nonparental adults
Tobacco use (tool not specified); annual alcohol volume (survey instrument); drug use (DUDIT-E)
12-mo follow-up compared to baseline—intervention compared to control: Being drunk last month: OR 1.05, 95% CI 0.48–2.27; P = .91; no alcohol use: OR 0.90, 95% CI 0.40–2.04, P = .81); illicit drug user: OR 1.68, 95% CI 0.25–11.09, P = .59). No significant differences for intervention vs control
Youth grades 4 to 9 registered with 8 Big Brother Big Sister agencies (n = 1138)
Total study duration 18 mo; follow-up at 9 and 15 mo
Intervention group: mentoring relationship with a Big Brother or Big Sister: support to inhibit initiation of alcohol, drugs and delinquent behaviors; wait-list control group: youth pending match with a Big Brother or Big Sister
Initiation of alcohol or drug use (self-report)
For 934 who had not used illegal drugs at baseline: 107 (11.47%) started using drugs; change in likelihood of using illegal drugs compared to control = −45.8. For 742 who had not used alcohol at baseline: 198 (26.72%) started using alcohol; change in likelihood of using alcohol compared to control = −27.4 (no statistical analysis provided). Herrera
Youths (average 11.4 y) with an HIV/AIDS parent recruited from agencies providing services to HIV-positive individuals (n = 157)
Total study duration 1 y; follow-up at completion of intervention at 1 y
Peer mentoring group: trained junior peer mentors with adult supervision, plus regular services and referrals for parents/youth. Mentoring combined with education, support groups, recreational/cultural activities, and tutoring/career development. Wait-list control group: also referred to recreation groups at local agencies
Use of tobacco, alcohol, or other substances in past year (self-report)
Number of peer mentoring sessions attended at 1 y correlated with a reduction in substance use (r = −0.35, P = .018). Intention-to-treat analysis of mentoring vs control at 12-mo follow-up: OR 0.64, 95% CI 0.04–9.97, Z = 0.32, P = .75) (NS)
Total study duration 3 school years. Pretest survey at beginning of program; posttest survey at end of school year
Across Ages program to reduce adolescent drug use. Mentoring group: (1) mentoring by elder, and adolescents help older adults (55+) maintain active roles, (2) PYDC: critical thinking/problem solving, community service, parent workshops, family activities. Curriculum Group: PYDC. Control Group: No intervention
Frequency of alcohol, tobacco and other drugs during previous 2 mo (self-report)
Frequency of substance use: mentoring group lower compared to program group: ANOVA F(1, 315) = 3.67, P < .056. Program group higher compared to mentoring and control groups: ANOVA F(1, 315) = −3.67, P < .056
Meta-analysis: We were only able to meta-analyze 2 RCTs for alcohol use Baseline nondrinkers at 12-mo follow-up (Bodin 2011) and 18-mo follow-up (Grossman 1998) mentoring compared to control: OR 0.72, 95% CI 0.58–0.90, Z = 2.86, P = .004; χ2 = 0.00, I2 = 0%
RCT = randomized controlled trial; PYDC = Positive Youth Development Curriculum; OR = odds ratio; CI = confidence interval.
randomly assigned 90 homeless youth in a US city (of whom 29 were 14 to 18 years of age) either to substance abuse treatment plus mentoring or to substance abuse treatment for 6 months. The mentors were asked to help the youth set goals, access Medicaid, housing, and food resources, identify rewarding recreational activities and alternative support systems, and transition to alternative support systems. In a 2011 study, Bodin and Leifman
recruited 128 14-year-olds (who had expressed a desire for more adult contact) from 28 schools in 3 Swedish cities through the Swedish Mentor Foundation. They were expected to meet with their mentor for 2 to 4 hours every 2 weeks. Mentees chose their own activities, and the mentors received supervision from a program director or psychologist.
recruited all 1138 students ages 10 to 16 who approached 8 Big Brothers Big Sisters agencies from 1991 to 1993 and randomized them to either mentoring (average duration 12 months) or a wait list. The mentors were young (79% were 20 to 34 years) and well educated (87% some college, college graduate, or graduate degree), and functioned as friends, with 42% meeting weekly and another 24% meeting at least 3 times/month.
recruited 61 adolescents (average age 11.4 years) with an HIV-positive parent from community organizations and agencies that serve HIV-positive clients and randomized them to either 1) weekly meetings with older peers (supervised by an adult) with recreational activities, field trips, and in-house activities (storytelling, arts and crafts, poetry, public speaking, coping strategies to deal with peer pressure, and Internet use), or 2) no intervention other than referral to local agency recreational groups. The youths were followed for 1 year.
in a C-RCT, recruited 562 6th graders at 3 public middle schools in Philadelphia, and randomized them to either 1) being mentored during the 6th grade school year and summer by adults aged 55 years or older from the community, a community service program (visits to frail seniors in nursing homes over an 8-week period, and planting trees or cleaning up a neighborhood or planting a community garden), participating in monthly parent activities and support workshops, and the 27 lesson school-based PYDC curriculum, or 2) community service, parent workshops, and the PYDC. Three cohorts of 6th graders were followed each for a year during 1991–1994.
was at low risk of bias for random sequence generation. The other 5 studies were at unclear risk of bias because they stated only random allocation without describing a strong method. All 6 were at unclear risk for allocation concealment because they made no statement to that effect. Only the study of Taylor et al
was rated as being at high risk of bias for attrition, while the remaining 4 studies were rated as unclear as they reported no differential attrition analysis. No study described blinding (which would have been possible for outcome assessors and data analysts). All 6 studies were at low risk of bias for selective reporting and other biases (Fig. 4).
none found statistically significant differences or odds ratios that did not include the null effect line. We were able to pool only Grossman and colleagues
and computed an odds ratio of 0.72 (95% CI 0.58–0.90; z = 2.86, P = .004, χ2 = 0%, I2 = 0%).
Drug Use
Six RCTs provided evidence about mentoring and drug use. The results could not be pooled because of differences in outcome measures. Two RCTs reported positive results. Aseltine et al
found that only 53% of the students randomized to peer mentoring actually attended mentoring sessions. For those who attended, mentoring was associated with less substance use (P = .018). (However, for the entire sample of 157, we computed an odds ratio of 0.64 [95% CI 0.04–9.97; z = 0.32, P = .75].) Taylor et al
combined tobacco, drugs, and alcohol, and at the 3-year follow-up found that while the mentoring group had less substance use than the curriculum group (P < .056), the control group also reported less substance use than the curriculum group (P < .056).
Four studies found no relationship of mentoring and drug use. Bodin and Leifman
investigated the use of 9 categories of illegal drugs within a 6-month time period and found no significant results (OR 1.68, 95% CI 0.25–11.09, P = .59). The sample of Bartle-Haring et al
We were unable to pool the 6 RCTs that provided evidence on mentoring and drug use. Of these, only 2 found any support for mentoring. A 2009 review of mentoring in adolescence identified 6 literature reviews, 16 program evaluations, and 5 meta-analyses.
This review concluded that most mentoring studies are not rigorously evaluated, do not test which are the core elements of mentoring, and do not assess how mentoring could meet the needs of mentees with different genders, social situations, and cultures.
A review of 53 randomized interventions with US African American children and adolescents identified 10 studies that were conducted according to manuals and 29 studies that were evaluated.
Of the 6 that focused on substance use, 2 were family based and 4 school based. None used a mentoring intervention. This review concluded that programs that have strong family acceptance, create community partnerships, are of high intensity, and meet consistently and frequently are more successful.
The next step in evaluating the effects of mentoring on alcohol and drug use in adolescents would be to conduct RCTs that are at low risk of methodological bias (ie, at low risk of bias in the randomization process, concealment of allocation, blinding where feasible, and low attrition) and adequately powered. The Big Brothers/Big Sisters International Web site (http://www.bbbsi.org) notes mentorship programs in 12 countries. Establishing and evaluating a standardized drug and alcohol mentoring intervention with valid and reliable outcome measures could be accomplished through this organization. Alternatively, interventions could be coordinated through the sites of the National Longitudinal Study of Adolescent Health, a large, nationally representative sample of middle and high schools in the United States.
Four RCTs provided evidence on mentoring and alcohol use; the 2 studies that could be pooled showed less alcohol use by mentored youth. Although the 6 RCTs that provided evidence on drug use could not be pooled, 2 provided some evidence that mentoring is associated with less drug use. Very few well-designed studies have evaluated the effects of mentoring on adolescent drug and alcohol use.
Acknowledgments
A new literature search was undertaken through January 27, 2013, and the original review updated and rewritten: Thomas RE, Lorenzetti D, Spragins W. Mentoring adolescents to prevent drug and alcohol use. Cochrane Database of Systematic Reviews 2011;(11):CD007381. Funded in part by a grant from the Canadian Tobacco Control Research Initiative .
References
UN Office on Drugs and Crime
World Drug Report, 2011.
United Nations Office on Drugs and Crime,
Vienna, Austria2011
Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. Ver 5.1.0. Cochrane Collaboration; 2011. Available at: http://www.cochrane-handbook.org/. Accessed June 7, 2013.
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