Youth Problem Gambling
Gambling disorder (GD) is defined as recurrent and persistent gambling activities resulting in clinically significant distress or impairment (American Psychiatric Association
2013). Core features of this diagnosis include preoccupation with gambling, restlessness or irritability when attempting to quit, and feeling a need to bet more money with increasing frequency. Although typically conceptualized as an adult disorder, there is increasing concern about youth gambling problems (Keen et al.
2017; Messerlian et al.
2005; Richard and Derevensky
2017) as illegal betting activities have become more common among adolescents. Recent estimates suggest that between 60 and 80% of youth under 17 years of age have gambled at least once during the past year (Delfabbro et al.
2014; Turchi and Derevensky
2006), with approximately 35% participating in such activities once a week. In fact, despite bans on youth gambling, a greater percentage of individuals under 18 participate in such activities at more problematic levels than adults (Ladouceur et al.
2013); 2% of adults meet criteria for GD as compared to 4–8% of adolescents with an additional 10–15% categorized as at-risk. Youth problem gambling has become a serious public health issue (Derevensky and Gupta
2000; Jacobs
2000; Richard and Derevensky
2017) that needs to be better researched to inform prevention and intervention strategies.
Much like adults, youth with problem gambling habits are susceptible to serious mental health, occupational, and relational consequences. Those whose gambling has negatively impacted their day-to-day functioning are at increased risk of developing anxiety (Gupta and Derevensky
1998; Richard and Derevensky
2017) and depression, in addition to comorbid substance abuse problems (Hardoon et al.
2004; Zhai et al.
2017) and illicit drug use (Peters et al.
2015). Wynne et al. (
1996) also found that adolescents with problem gambling behaviors were more likely than peers to have strained relationships (familial and/or peer), engage in criminal behavior, and perform poorly in academic settings. The latter consequence may be uniquely harmful to youth considering the high value placed on education and the critical importance of academic achievement as it relates to employment opportunities and long-term upward mobility.
The range of aversive consequences related to GD is well documented in the literature, but only recent studies have highlighted the disproportionate vulnerability of specific populations. While more research and replication studies are needed, ethnicity and gender were identified by Simmons et al. (
2015) as the two socio-demographic variables with which gambling behaviors were most significantly associated. Findings suggested that males endorsed more frequent gambling activity as compared to their female peers in a high school sample (ages 14–19), with 10.8% of males meeting criteria for at-risk or problem gambling but only 2.1% of females (Barnes et al.
2009; Simmons et al.
2015; Welte et al.
2009). In terms of ethnicity, African-American students appear to be at increased risk of problem gambling as 9.7% reported daily gambling activity as compared to only 4% of their Caucasian counterparts (Goicoechea et al.
2014; Lynch et al.
2004; Stinchfield
2000).
Furthermore, it appears that youth in urban settings endorse significantly higher rates of gambling related behaviors. A study conducted by Wickwire et al. (
2007) found that 22% of males and 5% of females in an urban high school sample reported problem gambling. Perhaps more alarming, approximately one-third (31%) of males and 12% of females endorsed levels of activity placing them at-risk for problem gambling (Wickwire et al.
2007). Taken together (Messerlian et al.
2005), it is clear that effective gambling prevention programs aimed at increasing youth knowledge and awareness are critically important, particularly for African American males and urban youth.
Gambling Prevention Programs
The literature indicates that there have been increasing efforts to develop and implement universal gambling prevention programs for youth (Keen et al.
2017; Ladouceur et al.
2013). Ladouceur et al. (
2013) evaluated 13 of these programs and rated the research integrity of each as determined by five domains; presence of theoretical model, research design, measurement properties, follow-up evaluations, and replication studies. Programs categorized as “Gambling-Specific Prevention Programmes” were 1 session activities delivered in school settings with aims to provide basic information about problem gambling and associated risks (Ladouceur et al.
2013).
Each of nine identified programs reported use of pre–post measures and noted increases in student knowledge at post-assessment. Four other studies assessed for positive appraisal of gambling behaviors and analyses yielded significant decreases following participation in the respective programs. However, the “Gambling-Specific Prevention Programmes” have noteworthy limitations. First none of the programs conducted follow-up evaluations to assess for maintenance of learning over time and to consider the impact of the program on gambling behavior. Gauging long-term benefits following participation is critically important considering the brevity of these prevention activities in comparison to other interventions. Additionally, none of the studies were replicated to support initial results and generalization of findings to other settings and populations.
One other category of prevention programs identified by Ladouceur et al. (
2013) was “Gambling and Related Skills Workshops.” These programs were implemented over multiple sessions and included practical activities encouraging student contributions as they learned specific information and skills. The four programs evaluated were McGill Adolescent Gambling Prevention CD-ROM (Williams
2002), Gambling: A Stacked Deck’ program (Williams et al.
2004,
2010), A Three-Session School-Based Awareness Workshop (Ferland et al.
2005), and A Curriculum of Problem Gambling (Turner et al.
2008). In addition to improving youth knowledge about gambling, this group targeted learning of broad skills potentially associated with problem gambling behaviors, including decision making, self-monitoring, and positive coping skills. Further, each program assessed for youth gambling, such as the amount of money and time spent on these activities.
General findings indicated small to moderate changes in youth gambling knowledge and targeted skills (i.e., decision-making, self-monitoring, coping) at post-assessment. Two research groups conducted follow-up studies yielding sustained effects of associated knowledge concepts at 4 months post-program (Williams et al.
2010) and maintenance of attitudes toward gambling 6 months after participation (Ferland et al.
2005). However, when analyzing the impact of teaching broad skills on youth engagement in risky gambling behaviors, only one study attained significant findings.
The program entitled “
A Stacked Deck” (Williams et al.
2010) included a booster session (i.e., session 6) and found sustained changes in decision-making skills, as well as decreased frequency of gambling and related problems. These important gains were attributed to the
Booster Program, added to the
Standard “
A Stacked Deck” curriculum, that reviewed material covered during the preceding five sessions.
When compared to the former group of prevention programs, “Gambling and Related Skills Workshops” demonstrate promise in being able to effectively impact sustained youth gambling knowledge and skills. Be that as it may, the aforementioned programs are not without limitations. First, of the studies that included follow-up evaluations and replications (Ferland et al.
2005; Williams et al.
2004,
2010), findings were inconsistent. In the examination of “
A Stacked Deck” specifically, modification of independent variables (i.e., adding the
Booster Session) may have contributed to the discrepancies and warrant further investigation of program effectiveness. Second, most prevention programs had no effect on participant skill development and ultimate engagement in problematic gambling behaviors (with the exception of Williams et al.
2010). Third, the programs demonstrating effectiveness require six or more sessions and have not been evaluated for utilization with middle school youth, limiting the degree to which interventions can be generalized younger adolescents. A final limitation to explore is the lack of emphasis on urban, African American youth in gambling prevention efforts. Given the unique vulnerability of this population, the effectiveness of gambling prevention programs should be examined for youth at greatest risk of developing gambling related problems.
Taken together, many independent research groups have taken interest in youth gambling problems and developing prevention programs to support increased knowledge and skills amongst this population. Unfortunately, the current literature lacks effectiveness and efficacy studies to validate existing programs, remains undecided on essential concepts to be included in prevention programs, and evidences few efforts to intervene with urban, minority youth. The youth gambling prevention community is in need of additional innovations that have been validated for more diverse populations (ethnic, cultural, age, gender).
Smart Choices
The Maryland Center of Excellence on Problem Gambling piloted the
Smart Choices program in collaboration with the Center for School Mental Health with aims of refining the curriculum as needed and working ultimately towards replication studies and randomized control trials. The
Smart Choices program is a four-session, non-curriculum based middle/high school gambling prevention program led by a trained facilitator (International Centre for Youth Gambling Problems & High-Risk Behaviors
2004,
2006). Through use of interactive PowerPoint, the program aims to increase youth awareness and knowledge of inherent risks associated with gambling. Additionally, the
Smart Choices program emphasizes positive decision-making skills which is considered an area of deficit in individuals with problem gambling habits (Dickson et al.
2002; Williams et al.
2010). Positive decision-making skills have been targeted in other youth gambling prevention programs (Williams et al.
2010).
The Smart Choices program is comparable to previously discussed programs in many ways, including goals to increase knowledge, emphasis on decision-making skills, and the lack of empirical evidence to support its effectiveness. However, this program was successfully implemented during a pilot study in Philadelphia Public Schools from 2009 to 2012 led by the Council on Compulsive Gambling of Pennsylvania, Incorporated (unpublished work). Additionally appealing aspects of the program include large-scale implementation with middle school youth, a reasonable of number sessions (i.e., 4), and the program’s utilization of activities intended to engage young audiences.
The Maryland Center of Excellence on Problem Gambling selected the Smart Choices program to intervene with Baltimore City youth due to the presence of large, thriving casinos in the community and increasing marketing promoting gambling behaviors. Initially piloted in four Baltimore City Public Schools in the 2013–2014 school year, the program experienced very limited success. In fact, it was discontinued mid-program in one school due to the lack of student engagement and severely disruptive behavior problems. Following program implementation, feedback was solicited from teachers, school-based mental health clinicians, and administrative staff about the programs strengths and challenges through a written survey.
Aims of increasing student knowledge about gambling and teaching decision-making skills were endorsed as preferred aspects of the program and viewed as important elements to retain. The main challenges noted were the style of delivery (e.g., PowerPoint, adult-driven) and developmental appropriateness of content. The latter concern included critiques of the data used to communicate prevalence rates (e.g., statistics that may be more resonant to adults) and difficulty of word problems used to practice application of skills. Coupled together, students could not identify with the curriculum and, in turn, were disengaged and susceptible to poor attention and disruptive behavior. Based on this feedback, the Maryland Center of Excellence on Problem Gambling in collaboration with the Center for School Mental Health adapted the program to better meet the learning needs and interests of students across urban middle and high school settings with predominantly minority populations.
Program Adaption: MD-Smart Choices
Literature indicates that an effective school-based prevention effort is theory driven, utilizes dynamic teaching modalities, supports positive youth-adult interactions, is culturally relevant, inclusive of outcome evaluation, and offers developmentally appropriate structure (Nation et al.
2003; Wentzel
2010). Given the well-established susceptibility of adolescents to risky behavior, mental health, and addiction problems, implementation of prevention activities attentive to their needs is critical. Therefore,
Smart Choices was adapted by the two Centers in 2014 to improve the relevance of material for youth and increase student engagement.
Theories of cultural adaptation guided modification of the Smart Choices to address the needs of an urban, predominately African American target population (Castro et al.
2004). Information gathered from the original Smart Choices content (i.e., a PowerPoint presentation) and surveys completed by clinicians during a focus group following pilot implementation in Baltimore City prompted adaptations focused on alignment of program
content with the developmental needs of urban, minority youth and form of program
delivery to fit into a typical school context (Castro et al.
2004). For example, original program
content favored advanced terminologies such as “chance” and “illusion of control” illustrated using complex, multi-step word problems. Adapted
content focused on simplification of language to reduce reading and math fluency barriers that are more likely to be present in urban, low-socioeconomic communities.
Characteristics of the delivery person (Castro et al.
2004) were also addressed. Given the well-established importance of positive relationships with adults for youth development (Nation et al.
2003), the development team partnered with providers trained to establish positive relationships with and support the social-emotional needs of diverse school communities. Master’s level school-based mental health clinicians, licensed or supervised outpatient therapists embedded within specific schools, served as primary delivery persons and co-facilitators during implementation of the adapted program. This adaptation was made to promote positive relationships with program facilitators and increase student accountability for behavior as clinicians are connected to school staff, leadership, and community through mental health promotion, prevention and intervention responsibilities.
Incorporation of varied teaching methods, a behavior chart, and outcome evaluation were other adaptations made to meet the developmental needs of urban, predominately African American youth. Changes to the teaching methods included encouraging student participation through group activities and discussions, revamping PowerPoint slides, incorporating hands on demonstrations, and providing a student workbook. Scenarios used for group discussion feature similarly aged youth with relatable interests (e.g., shoes) and social challenges (e.g., desire for peer group acceptance) further encouraging participant engagement with the material.
Finally, a brief assessment was developed to assess changes in participant knowledge about and attitudes toward gambling at prior to and following participation in MD-Smart Choices. Assessments include seven items where participants select “true,” “false,” or “don’t know” in response to youth gambling prompts. Additionally, a list of various activities requires discernment between activities requiring mostly luck as compared to items requiring mostly skill. To gauge existing gambling behaviors amongst participants, questions about experiences with lottery or scratch off tickets, dice games, card games, betting money on games of skill, and activities such as fantasy leagues are included.
The final version of the adapted program, referred to as the Maryland Smart Choices Youth Gambling Prevention Program (MD-Smart Choices), is a 3-session manualized curriculum designed to provide students with information about gambling, including risk factors associated with Gambling Disorder. Session one focuses on helping students to define gambling and differentiate between games of skill and luck. The second session introduces a decision making model and emphasizes the critical importance of positive choices as it relates to gambling, as well as other challenging situations (e.g., using drugs, alcohol). The third and final session asks students to employ the decision making model and apply acquired knowledge to role-play difficult, “real life” situations.
Additional features of the adapted program include a manual designed for utilization by experts or novelists in understanding and addressing mental health or gambling disorders (e.g., teachers, paraprofessionals, and administrators), a standardized set of classroom behavioral expectations, pre–post assessments of student gambling knowledge, and student worksheets for session activities. Much like other gambling prevention programs,
MD-
Smart Choices aims to increase student knowledge about gambling risks and fallacies (Keen et al.
2017). This program also emphasizes positive decision-making, a specific skill less frequently addressed by other gambling education programs (Keen et al.
2017). Other proximal goals include increasing student engagement in the prevention program and better standardization of implementation.
The current paper summarizes findings from the 2014–2015 implementation of the adapted MD-Smart Choices Youth Gambling Prevention Program. The goals of the pilot study were: (1) to implement the MD-Smart Choice program in 5 Baltimore City classrooms (middle and high), (2) ascertain degree of student engagement in gambling activities, (3) assess student knowledge about gambling as indicated by changes in pre–post assessment responses, and (4) explore the strengths and challenges of the adapted MD-Smart Choices program.