Provision of an Optional Drug Refusal Skills Training Module Does Not Improve Outcomes of African-American Adolescents with Substance Use Problems

Background and Importance: Social workers remain concerned with how to best tailor substance use disorder treatments to culturally diverse populations. Recent research found that African-American adults with alcohol use disorders benefitted more from receiving an optional drink refusal skills training (RST) session when compared to African-Americans that did not receive this procedure and Caucasians who did.  However, this study was very small, did not control for numerous confounds, and does not currently generalize to adolescents.  The purpose of this study was to attempt to replicate these findings with adolescents participating in a trial of a broad spectrum behavioral treatment for whom RST was an optional procedure.  Given prior research, we hypothesized that African-American adolescents receiving RST (AA+RST) would have better outcomes compared to two other groups, including: African-Americans who did not receive RST (AA-RST) and Caucasians who received RST (CA+RST).

Method.  A subset of cases were selected from a large SAMHSA-funded evaluation of Adolescent Community Reinforcement Approach (A-CRA) outcomes.  Participants (n=1757) were selected if they were treated in outpatient settings, had baseline measures and valid 3 or 6 month follow up data available for analysis, and reported their race as African-American or non-Hispanic White. (Using these criteria, 96.5% (n=1695) of all cases were available for analysis, with five cases excluded due to missing variables, and 57 cases missing follow up data.) AA+RST (n=214) were then matched to AA-RST (n=212) and CA+RST (n=173) using propensity score analysis.  Propensity weighted regressions used group membership to predict frequency of substance use at last follow, while controlling for overall quality of A-CRA and days elapsed between baseline and last follow up. 

Results:   Few differences existed between the AA+RST and AA-RST samples, and after matching there were no significant differences on variables we examined that could have confounded results. Matching eliminated differences for all but one variable for the comparison to the CA-RST group.  At follow up, there were no differences between AA+RST and AA-RST (B=.008; df=3,425; ns), with African-American clients who received the refusal skills training (AA+RST) showing slightly higher, albeit non-significant, substance use frequency at follow up.  Very similar findings emerged when the AA+RST group was compared to the CA+RST group (B=.01, df=4, 386).  Overall quality of A-CRA was a significant predictor of substance use frequency in the model comparing AA+RST and AA-RST groups. 

Conclusions and Implications:  We failed to replicate the positive findings from prior research suggesting that refusal skills training may differentially benefit African-Americans with substance use problems.  It is possible that prior findings were due to how previous research controlled for exposure to treatment (days of treatment vs. number of procedures used).  This study does not support the notion that universal receipt of RST would improve the outcomes of African-American adolescents, and clinicians using A-CRA should continue to use RST flexibly when they recognize that their clients may benefit from it.