JOURNAL OF ADOLESCENT HEALTH 1991;12:606-613

lems of Alcohol and Other Drug Use and Abuse in Adolescents HOOVER

ADGER,

JR., M.D.,

M.P.H.

Intrixiuction During the past 20 years, the medical community and the general public have become increasingly aware of and concerned about the level of drug involvement among our youth. Accordingly, the recognition of the epidemic use of alcohol and other drugs and its emergence as a major health problem for youth has stimulated large-scale epidemiological studies which have increased our knowledge of the nature, trends, and consequences of such use. This paper will explore causal theories of adolescent alcohol and other drug use, characteristics of the population at risk, and perplexing questions which arise owing from the lack of information regarding assessment and treatment. Finally, it will examine the need for a more clearly defined role for the health care provider in the prevention, early identification, treatment, and/or referral of alcohol- and other druginvolved youth. Although the specific focus here will be on alcohol and other drugs, it is important to keep in mind their association with three other major topics: acquired immunodeficiency syndrome (AIDS), violence, and sex. Overall Description of the Problem At the end of the l%Os, the use of illicit drugs among adolescents and young adults was recognized as a major epidemic. Large segments of the nation’s youth had begun to experiment with marijuana,

From the Departnrent of Pediatrics, lohns Hopkins Hospital, Baltinlo~. Address rvprint requests to: Hoover Adger, M.D., M.P.H., Assistant Pmjizssor, Department ofPediatrics, Park 307, Iohns Hopkins Hospital, 600 83. Wolfe St., Baltimore, MD 21205. Mandpt awepted September IYYl.

PCP, and other psychoactive drugs. Moreover, misuse and abuse of prescription drugs (e.g., tranquilizers and stimulants) were on the increase. By the mid-1970s, experimentation with illicit drugs seemed to have become synonymous with other “rites of passage” into adulthood. Although the rate of drug use for most psychoactive substances declined during the late 1970s and early 198Os, its prevalence among adolescents and young adults continues to be a significant problem. As measured by the Monitoring the Future Survey, in 1989, 19% of high school seniors reported having smoked cigarettes daily, 4% were drinking alcohol daily, and 3% used marijuana daily. More than 90% of high school seniors reported some experience with alcohol at some time in their life; the comparable figures for marijuana and cocaine were 44% and 10% respectively. Of seniors 60% reported use of alcohol within the past month, and 33% had had five or more drinks in a row in the past 2 weeks. Moreover, slightly more than one half of the seniors had tried an illicit drug (1). One disturbing observation is that although there has been a decrease in the reported prevalence of use of most illicit drugs, there has been little change in the reported use of alcohol, which is the major drug of abuse. Additionally, there has been a trend toward earlier initiation of drug use. The Alcohol Epidemiologic Data Systems of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) report that the average age for initiation of alcohol or drug use is I4 years. There is also an inclination among today’s youth to use more than one drug simultaneously. Among current users in a recent statewide survey of adolescents, the average young adolescent (eighth grader) used 3.4 drugs (2). This, too, is disturbing since recent data suggests that high levels

~b~~h~ byEkvier Science Publis+g

6 Society for Adolescent Medicine, 1991 Co., Inc., 655 Avenue of the Americas, New York, NY 10010

December 1991

ot polydrug drug-related

PROBLEMS OF ALCOHOL AND OTHER DRUG ABUSE

use as a teenager zre associated with problems later in life (3).

Impact on Health Status A major factor in the deterioration of the health status of adolescents and young adults is use of alcohol and other drugs. It is a major contributor to disability and death for individuals in the 15- to 25-year-old group. The leading causes of death in teenagers are accidents, homicide, and suicide. Approximately one half of fatal motor vehicle accidents and homicides, as well as a significant proportion of suicides, are associated with the use of alcohol and other drugs (4,5). Of equal concern is the impact of alcohol and other drugs on the cognitive and psychosocial development of young people. Moreover, substance abuse and dependence syndromes make a significant contribution to the leading cause of chronic disabilities-mental disorders-which affect an estimated 634,000 adoles,cents (6).

Why A@Jd&%ts Continue to Be Involved: Thtm.6 3 of Cuusa tion A number of theories of drug use can be identified from the research literature. Problem behavior theory suggests that drug use is interrelated with other problem behaviors with which it has common al Itecedents. Jessor and Jessor originally hypothesized that many problems, including abuse of alcohol and other drugs, could be explained by variations in individual personality characteristics, perceived environmental structures, socialization patterns, and demographic status (7). Subsequent empirical research supports Jessor and Jessor’s arguments. In general, a low value placed on education or low expectations for academic achievement, a high tolerance of deviance, and a high value placed on personal independence are associated with teenage drug use. Perceptions of parental and peer modeling of drug use and adolescents’ perceptions that peers or parents approve of or tolerate drug use were also associated with the use of drugs (8). Several investigators have examined the relationships among adolescent problem behaviors and have identified characteristics which commonly precede them. Common antecedents include early antisocial behavior, parental and sibling modeling of drug use and delinquency, poor family management, family conflict, low value attached to education, alienation from dominant social values,

607

community disorganization, and geographic mobdity (9-13). According to Bandura, learning is shaped by the observation of other people’s behavior and its consequences for them. Bandura recognized the potential use for “modeling” as a way of directing and modifying behavior through the transmission of messages depicting behavior and attitudes that young people would like to imitate. Bandura also noted that the ability to anticipate both the consequences of one’s behavior and the attitudes of others toward such behavior develops as an individual matures (14). Social learning theory expands problem behavior theory by suggesting that behavioral patterns are more or less problematic depending on the opportunities and social influences to which one is exposed, the skillfulness with which one performs, and the balance of rewards one receives from participation in certain activities. Accordingly, the rewards one receives for behavior directly affect the likelihood that one will continue that behavior, and the risk of problem behavior is reduced when young people have an opportunity to perform skillfully in conventional settings (15). Kandel and co-workers empirically tested the hypothesis that drug involvement progresses through a series of stages which begins with experimentaGun, progresses to regular use, and then res$ts in dhb&_k~~lWkc

1.

.- --

I?L\ (&w).

St;_&

thnory

p’“p”ses

that

within normal adolescent populations, drug; use tends to follow several stages, each of which is necessary but not sufficient for progressing to the next stage. For those who progress beyond initial experimentation with tobacco and alcohol, regular use of alcohol is next, followed by the use of marijt$ana in conjunction with tobacco and alcohol, and then the use of prescription or illicit drugs. Opponents of the stage theory argue that no one path leads to drug use or abuse; they suggest instead that drug abuse is a function of a number of problems experienced by adolescents. Multiple-riskfactor theory suggests that drug use is caused by a combination of factors, none of which alone is causative (9,17). The biopsychosocial model, emerging from the field of behavioral medicine and from recent interest in competence and coping, is based on two central premises (18): The first is that substances may be used as a coping mechanism to enlhance desirable or reduce undesirable feelings or emotions; the second is that skills used to cope with stress of daily life situations are different from those used for cop

40s

ADGER

ing with temptation to experiment with or experience the effects of a mood-altering substance. The model suggests that substance abuse is a product of a deficiency in coping skills that are relevant to a variety of stressors. Hence, when faced with personal or social pressure to use substances, youth with deficits in social skills are more likely to engage in drug use. The social stress model proposed by Rhodes and Jason integrates the traditional emphasis on individual and family variables with recent research on competence and coping (19). Drug use is viewed as a long-term outcome of multiple experiences with significant others and social systems from birth to adolescence. Accordingly, adolescents who: (1) form positive attachments with family, teachers, and peers; (2) develop good coping skills; and (3) have school and community role models in addition to resources in the community which provide opportunities for success are more likely to deal with stress effectively and less likely to engage in problem behaviors, including use of alcohol and other drugs. The model suggests that it is important to examine the broader social context in an attempt to minimize the social and institutional obstacles to adjustment for youth, such as enhancing their educational opportunities and improving the quality of school systems. Additionally, it emphasizes the importance of examining broader variables, such as socioeconomic status, race, school environment, and community resources, in determining risk.

Youth at High Risk A major concern is early identification of youth at high risk to permit the interruption of behaviors that would otherwise lead to alcohol and other drug use and/or other dysfunctional behaviors and to do so without inappropriate negative labeling. In the earliest school grades, youngsters at risk may be distinguishable from others by aggressive antisocial behavior (20). In particular, youth who manifest the combination of shyness and aggression and those who have school adjustment and truancy problems have been shown to be at increased risk (21,22). By the late elementary grades, youngsters at highest risk are those who have experienced school failure (23). By adolescence, a low commitment to school and associated academic failure may be evident (24,25), as may be delinquent, drug-using friends (26), alienation from the larger society (27,28), and associated rebelliousness (23-25,29). Early identifi-

JOURNAL OF ADOLESCENT HEALTH Vol. 12, No. 8

cation of those at high risk, meaningful intervention, and prevention of these negative consequences are issues of major importance. Risk for alcohol and other drug use can be seen as falling into five broad categories: genetic and family factors, peer factors, psychological factors, biological factors, and environmental factors. In addition to these broad categories, several demographic variables have been used to characterize youth at risk. Genetic and Family Factors A number of genetic and family factors put youth in high-risk categories. There is increasing evidence for genetic factors, especially for sons of fathers who had early onset of drinking problems (31-34). Twin studies suggest genetic factors with regard to alcoholism among males (35,36). Individuals with a family history of alcoholism have a four- to sixfold increased risk for the same disorder when compared to the general population (37). A family history of antisocial behavior is another risk factor. Children with parents or siblings who exhibit antisocial behavior are at increased risk of developing alcohol and other drug problems (38). Additionally, there is evidence that poor parenting skills increase the risk of having children who use alcohol and other drugs (39-41). Parental alcohol and other drug use, as well as attitudes favorable to such use, are other familial risk factors for teenage substance use (27,42,43). Peer-ReIated Factors One of the most powerful predictors of alcohol or other drug use by an adolescent is the drug use of the youth’s best friend (24,26,44,45). Adolescents whose friends use drugs are much more likely to use them than those whose peers do not. There is also good evidence that initiation into drug use is more often by friends than by strangers. Additionally, youngsters having older siblings involved with alcohol or other drugs are also more likely to become involved themselves (26). Psychological

Factors

A wide variety of psychological factors are known to be associated with alcohol and other drug use. These include school failure (46), low interest in school and achievement (27), rebelliousness and alienation (25,27,47,48), low self-esteem (49), and early antisocial behavior (13,21,46). Although the

December 1991

psychological factors are less well understood, a constellation of character traits that is associated with high risk of alcohol and other drug problems among teenagers has been identified. These characteristics include lack of empathy for the feelings of others, easy and frequent lying, favoring of immediate over delayed gratification;. and insensitivity to punishment. Youths with these character traits are especially vulnerable to alcohol and other drug problems as well as to other problem behaviors (25,50). Biological Factors One of the most important developments in alcohol and other drug research during the past two decades has been the exploration of the biological aspects of alcohol and other drug dependence. Although much remains unclear, it appears that once a person has been dependent on alcohol or other drugs, that individual remains biologically different from others who have never used drugs, one factor which makes relapse common (51-54). Environmental Factors Environmental characteristics have long been known to play a major role in the causes of delinquency and, by extension, in the development of substance use. The relationships among population density, community disorganization, and delinquent behavior are well established (54). Moreover, it appears that persistent drug use and delinquent activity, as opposed to infrequent or occasional alcohol and other drug use, is associated with deprivation and an altered sense of reality in adulthood (55). Demographic Factors Demographic variables, such as age, ethnicity, race, and socioeconomic status, have been examined with regard to their impact on adolescent alcohol and other drug use. Age is most consistently associated with problem drug use. Kandel and others have shown that initiation of alcohol use at a young age influences the risk of using marijuana and that early use of marijuana increases the risk of involvement with other illicit drugs (16). Early experimentation leads to a higher risk of drug abuse compared to that at a later age (56). The earlier a person begins to drink or use other drugs, the greater the likelihood of later drug problems. In particular, using drugs before age 15

PROBLEMS OF ALCOHOL AND OTHER DRUG ABUSE

609

years greatly increases the risk of later drug use. Current research suggests that delaying the age of onset of experimentation with alcohol and other drugs may prevent later and more serious drug invoiuement. Gender is not a good predictor of adolescent drug use (57). Differences between male and female drug use have declined over the past two decades. These differences are relatively small and vary by type of drug, level of drug i:rvolvement, and age. In general, although differences between male and female use patterns for cigarettes are minimal, males are more likely to report higher levels of illicit drug use and are more likely to report episodes of binge drinking and heavy use of illicit drugs (16,58). These gender differences do not appear to be sufficiently large to merit gender-specific drug prevention programs. However, sex-specific approaches may be warranted for treatment (59). Also, there are specific populations of adolescents, such as pregnant teenagers, with sufficiently different needs to merit a special approach (60). Ethnic and racial differences in alcohol and other drug abuse are difficult to determine because these variables are often confounded by socioeconomic status and living conditions (58,61,62). Although White youth compared to non-White youth have reported consistently higher levels of use of alcohol, marijuana, cocaine, and other illicit drugs, differences between these groups are now very small. In general, White and Native American youth, especially those in urban areas, report the highest rates of use, Hispanic and African-American youth report intermediate rates of use, and Asian-American youth report the lowest rates of use. Among ethnic groups, use rates vary by age and gender (57,63,64). Hence, to be effective, prevention and treatment programs need to be sensitive to cultural, environmental, economic, historic, and demographic distinctions that affect alcohol- and drug-related behaviors within racial and ethnic subcultures. Socioeconomic status alone is not strongly associated with substance abuse (10,58,64). Substance abuse and dependency cut across all income and socioeconomic categories. Education, a factor closely related to socioeconomic status, does show a correlation with use of alcohol and other drugs. Students who are doing well in school report lower rates of use than those who are doing poorly. In addition, students who have plans to attend college are less likely than those without such expectations to engage in illicit drug use (65). It is important to realize that risk factors are sim-

610

ADGER

ply characteristics which refer only to higher probabilities of a problem’s occurring. Many children who grow up under highly adverse conditions still manage to become healthy, well-functioning adults (66). Although the presence of risk factors may help to identify those who are most vulnerable, it does not mean that any individual who exhibits them will inevitably develop problems.

The Need for Evaluation and Treatment Clarification Although there has been extensive research on the trends of drug use and the process by which adolescents become involved, there has beer. a paucity of clinical research that distinguishes experimentation from abuse_ Should all use of psych.oactive substances by youth that is not medically eupervised be considered abuse? Is exherimentation a part of “normal” adolescent growth and development? What are the distinguishing features of those who are at risk of progressing to problem use? These are only a few of the perplexing questions which are currently areas of active debate. UnfortunateJy, there has been very limited study of the specifics of assessing the drug-using adolescent and matching an appropriate treatment with the level of involvement and severity. Currently an estimated 5.5 million Americans need drug treatment: slightly more than 2% of the total population above 12 years af age. Although most of these individuals are in the 18- to 34-year age group, youths under the age of 18 make up”) about 9% (about 400,000 persons) (67). There has been a proliferation of drug treatment programs for youths throughout the country, yet there has been very little outcome and evaluative research on the impact or therapeutic benefit of a particular treatment approach. In short, as reviewed in a recent Institute of Medicine report, the state of knowledge of adolescent treatment is less than satisfactory. The number of studies of adolescents is small and most work is based on research on treatment in much earlier periods. Most individuals who initiate drug use do not ds.dop sigr-.ificant social, vocational/educational, or psychological consequences of use. For some adolescents, however, drug use becomes habitual, problematic, and, not infrequently, life-threatening to self and others (68). For such individuals, treatment intervention is obviously required. Although it is clear that there is a need for specific treatment services for youth, type and length of treatment, match-

JOURNAL OF ADOLESCENT HEALTH Vol. 12, No. 8

ing of clients and treatment, involvement of family, and best ways of maintaining patients in aftercare are all important issues which need further study and clarification (69,70). It is also clear that there are many adolescent developmental issues which need to be examined and that require a longitudinal.approach. For example, Donovan, Jessor, and Jessor conducted a lo-year follow-up study of youthful drug abusers and reported that the majority of the adolescents moved to a lower level of alcohol and other drug involvement without treatment (71). Although it is generally accepted that treatment is superior to no treatment, such studies raise many questions regarding appropriate and cost-effective treatment approaches for the chemically abusing or dependent adolescent.

Enhancing Physician Participation in Early Zdentification and Treatment of Alcohol and Other Drug Problems Recent responses to this multifaceted problem have focused on prevention and treatment of substance abuse by enhancement of the role of the primary care physician. The importance of the physician’s role is supported by several studies which indicate that individuals with problems related to alcohol and other drug use and abuse make frequent visits or are seen exclusively in the primary care sector (72). Despite well-documented evidence of prevalence of the substance use and abuse among adolescents and the effects of parental drug abuse on children (73,74), physicians appear to have a strong cultural ambivalence or aversion to recognizing the problem in their patients (75). In a recent study, drawn from the general pediatric medical service of a large metropolitan teaching hospital, less than 5% of pediatric patients and their parents whose screening test results yielded positive findings for alcohol and drug problems were identified by resident or attending physicians (76). The American Medical Association and American Academy of Pediatrics have set forth practice standards for physicians’ responsibility for alcohol and other drug use screening and referral (77,78). Given the nature of their long-term relationship with patients and their families, practitioners who care for youth are in a unique position to recognize early, diagnose, treat, and refer patients and/or family members evidencing problems associated with the abuse of alcohol and other drugs. Unfortunately, lack of instruction about alcohol and other drug is-

December

1991

sues during medical training often precludes the physician from taking advantage of this unique relationship. The majority of physicians report discomfort in dealing with alcohol and other drug issues, and many lack the required :skills to screen and refer patients effectively. In a recent survey of primary care physicians by Weschler, respondents estimated that 5% or fewer felt successful in helping their patients with alcohol and other drug problems (79). A 1982 poll conducted by the American Medical Association indicated that only 27% of physicians felt competent to diagnose and treat alcoholic patients. Contributing factors identified by physicians included inadequate training, attitudinal barriers, and constraints of the medical education system (80). Although several surveys of medical school curricula have indicated an imprnvemcnt over the last decade, a large number of medical schools and residency training programs still teach very little about this subject (81). Moreover, despite ,acknowledging its importance, the majority of pediatric training programs do not currently offer or plan to offer any formal instruction in this area (82). It is only through increased familiarity with the complex arr,ay of problems associated with this chronic and relapsing health problem that physicians will be better able to assist affected patients. Efforts to improve the education of physicians on substance-abuse-related issues will not succeed unless sufficient time is made available within the medical education curriculum. However, a specified amount of time or the offering of a number of electives will not be enough to make a significant impact (83,84). Education and training related to substance abuse, as with other complex medical problems, will require multidisciplinary approaches and incorporation and use of appropriate educational methods to effect positive change in knowledge and attitudes, : as well as skills.

In summary, although there has been much progress, alcohol and other drug use and abuse in adolescents remains a major medical and public health problem. Epidemiological studies of adolescents and young adults provide important information about the frequency, quantity, and types of drugs used among these populations. A number of theories on causation and initizition of use of alcohol and other drugs have been postulated, and each adds i’rgortant new information to the field. Impressive gains

PROBLEMS OF ALCOHOL

AND OTHER DRUG ABUS’

611

have been m.ade in the identification of risk profiles which lead to alcohol and other drug use. Although this work has been comprehensive in its approach, studying the influences of family and peer factors, psychological and biological variables, and environmental and demographic characteristics, many questions remain unanswered with regard to the distinguishing features of those at risk who progress to problem use. Additionally, although treatment programs have been developed specifically to meet the special needs of adolescents, treatment outcome studies and better assessment procedures to determine which adolescents need which specific types of treatment are still needed. Finally, effective physician education strategies are needed to ensure appropriate practice behaviors among health care providers, who should be an important link in the coordination of efforts as the health care community responds to the problem of alcohol and other drug &use.

References .1. Johnston CD,

O’Malley PM, Bachr”lan ]G. High Sch~o/Stwior Drug Use 2975-89. Rockville, MD, National Institute on Drug

Abuse. 1990. 2. 1984 Shrvey of Drug Abuse Among Maryland AdolescentsGeneral Report. Baltimore, MD, Maryland Department of Health and Mental Hygiene-Drug Abuse Administration, (MDHMH), 1985. 3. Newcomb MD. Stabilization of drug use patterns from adolescence to young adulthood. Paper presented at the American Public Health Association Annual Meeting, Buston, November 1988. 4. Centers for Disease Control. Fatal injuries to children. United States, 1986. MMWR 19YO;39:42. 5. Surgeon General’s Report on Drunk Driving: 1988 Proceedings. Rockville, MD: DHHS, US Public Health Service, Office of the Surgeon General, 1989. 6. Newacheck PW. Adolescents with special health needs: Prevalence severity and access to health services. Pediatrics 1989; 841872. 7. lessor R, Jessor SL. Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth. New York: Academic Press, 1977. 8. Polich JM, Ellickson PL, Reuter P, et al. Strategies for Controlling Adolescent Drug Use. Santa Monica, CA: Rand, 1984. 9. Newcomb MD, Maddahian E, Bentler PM. Risk factors for drug use among adolescents: Concurrent and longitudinal analyses. Am J Public Health 1986; 76:525-31. 10. Dryfoos JD. Youth at Risk: One in Four in Jeopardy. Report submitted to Carnegie Corporation, 1987. 11. Hawkins JD, Lishner D, Catalan0 RF. Childhood predictors and the prevention of adolescent substance abuse. In: Jones CL, Battjes RJ, eds. Etiology of Drug Abuse: Implications for Prevention. Research Mancgraph No. 56. DHHS Publication No. (ADM) 85-1335. Washington, DC; US Government Printing Office, 1985. 17 _. Clayton RR. The delinquency and drug use relationship among adolescents: A critical review. In: Drug Abuse and ‘he American Adolescent. DHHS Publication No. (ADM) 841166. Rockville, MD, National Institute on Drug Abuse, 1984.

612

JOURNAL OF ADOLESCENT HEALTH Vol. 12, No. 8

ADGER

13. Elliott DS, Huizinga D, Ageton SS. Explaining Delinquency and Drug Use. Beverly Hills, CA: Sage, 1985. 14. Bandura A. Social Lcatning Theory. Englewood Cliffs, NJ: Prentice-Hall, 1977. 15. Botvin GJ, Wills ‘IA. Persona1 and social skills training: Cognitive-behavioral approaches to substance abuse prevention. In: Bell CS, Battjes R, eds. Prevention Research: Deterring Drug Abuse Among Children and Adolescents, NIDA Research Monograph No. 63. DHHS Publication No. (ADM) 87-1334. Washington, DC, US Government Printing Office, 1985. 16. Kandel DB, Yamaguchi K. Developmental patterns of the use of legal, illegal and medically prescribed psychotropic drugs horn adolescence to young adulthood. In: Jones CL, Battjes RJ,eds. Etiology of Drug Abuse: Implications for Prevention, Research Monograph No 56. DHHS Publication No. (ADM) 85-1335. Washington DC, US Government Printing Office, 1985. 17. Bry BH, McKeon P, Pandina RJ, Extent of drug use as a function of number of risk factors. J Abnorm Psycho1 (1982);

33. Schuckit MA, Engstrom D, Alpert R, et al. Differences in

34.

35. 36.

37. 38. 39.

9227339.

18. Wills TA, Schiffman S. Coping and substance use: A conceptual framework. In: Schiffman S, Wills TA, eds. Coping and Substance Use. New York, Academic Press, 1985. 19. Rhodes JE, Jason LA. Pmventing Substance Abuse Among Children and Adolescents. New York, Pergamon Books, 1988. 20. Ensminger ME, Kellam S, Rubin BR. School and family origins of delinquency. In: Van Dusen K, Medick S, eds. Prosoective Studies of Crime and Delinauencv. Boston. Klu. wer Academic, 1983. 21. Kaplan HB, Martin SS, Robbins C. Pathways to adolescent drug use: Self-derogation peer influene, weakening of social controls, and early substance use. J Health Sot Behav 1984; 25270-89. 22. Bachman JG, Johnston LD, O’Malley PM. Monitoring the Future: Questionnaire Responses from the Nation’s High School Seniors. Ann Arbor, MI, Survey Research Center, 1981. 23. Kelly D. The educational experience and evolving delinquent careers. In: Shichor D, Kelly DH, eds. Critical Issues in Juvenile Delinauencv. Lexineton. MA: Heath. 1980. 24. lessor R, Cldse JA,.Donov& JE. Psychological correlates of marijuana use and problem drinking in a national sampIe of adolescents. Am J Public Health 1980; 70:604-13. 25. Smith GM, Fogg CP. Psychological predictors of early use, late use and non-use of marijuana among teenage students. In: Kandel DB, ed. Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues, Washington, DC, Hemisphere, 1978. 26. Kandel DB. On processes of peer influence in adolescent drug use: A developmental perspective. Alcohol Substance Abuse Adolescence 1985,4:139-63. 27. Kandel DB. Epidemiological and psychosocial perspectives on adolescent drug use. J Am Acad Chid Psychiatry 1982; 21:328-47. 28. Jessor R, Jessor SL. Theory testing in longitudinal research on marijuana use. In: Kandel DB, ed. Longitudinal Research on Drug Use, Washington, DC, Hemisphere, 1978. 29. Annis HM, Watson C. Drug use and school dropouts: A Iongitudmal study. Can Counseling 1975;34~155-62. 30. Begleiter H, Porjesz B, Bihari B, Kissin B. Event-related brain p&cn?lals in boys at risk for alcoholism. science 1984; 225: 1493-%. 31. Elmasian R, NeviIle H, Woods D, et al. Event-related brain potentials are different in individuals at high and low risk for developing alcoholism. Proc Nat1 Acad Sci 1982; 79:79OO-3. 32. Schudrit MA. Self-rating of afcohol intoxication by young men with and without family histories of alcoholism. J Stud Alcohol 198Q 41:24249. 1.

40. 41. 42. 43. 44. 45. 46.

muscle-tension response to ethanol in young men with and without family histories of alcoholism. J Stud Alcohol 1981; 42918-24. Schuckit MA. A prospective study of genetic markers in alcoholism. In: Hanin I, Usden E, eds. Biological Markers in Psychiatry and Neurology. Oxford, Pergamon Press, 1983. Cadoret RI. -- Cain C. Grove WM. Develooment of alcoholism in adoptees raised apart from alcohol; biologic relatives. Arch Gen Psychiatry 1980; 37561-63. Pickens R, Svikis D. Use of the twin method in the study of vulnerability to drug abuse. In: Genetic and Biological Markers in Drug Abuse and Alcoholism. National Institute on Drug Abuse, Research Monograph Series No. 66. Washington. DC. US Government Printine Office. 1986. Goodwin DW. Alcoholism and gezetics. Arch Gen Psychiatry 1985; 42171-74. Robins LN. Deviant Children Grown Up. Baltimore, MD, Williams & Wilkins, 1966. Kumpfer JL. Special populations: Etiology and prevention of vulnerability to chemical dependency in children of substance abusers. In: Brown BS, Mills AR, eds. Youth at High Risk for Substance Abuse, Rockville, MD, National Institute on Drug Abuse, 1987. Penning M, Barnes GE. Adolescent marijuana use review. Int J Addict 1982; 17:749-91. Simcha-Fagan 0, Gersten JC. Early precursors and concurrent correlates of illicit drug use in adolescents. J Drug Issues 1986; 60~7-28. Kandel DB, Kessler R, Margulies R. Antecedents of adolescents’ initiation into stages of drug use: A developmental analysis. In: Longitudinal Research in Drug Use. 1978. Thorne CR, DeBlassie KK. Adolescent substance abuse. Adolescence 1985; 20~335-47. Kaplan HB, Martin SS, Robbins C. Applications of a genera1 theory of deviant behavior: Self-derogation and adolescent drug use. J Health Sot Behav 1982; 23274-94. Norem-Hebeisen A, Johnson DW, Anderson D, et a!. Predictors and concomitants of changes in drug use patterns among teenagers. J Sot Psycho1 1984; 1244350. Robins LN. The natural history of drug abuse: In Evaluation ;i8\eg;t of drug abusers. Acta Psychiatr Stand Suppl

47. Kumpfer iL;DeMarsh J. Family-oriented interventions for the prevention of chemical dependency in children and adolescents. In: Ezetoye S, Kumpfer K, Bukoski W, eds. Childhood and Chemical -Abuse: Prevention and Intervention, New York, Haworth Press, 1986. 48. Holmberg MB. Longitudinal studies of drug abuse in a fifteen-year old population. Acta Psychiatr Stand 1985; l&12936. 49. Kumpfer JL. Prevention of Alcohol and Drug Abuse: A Critical Review of Risk Factors and Prevention Strategies in Prevention of Mental Disorders, Alcohol and Other Drug Use in Children and Adolescents. DHHS Publication No. (ADM) 89-1646. Washington, DC, US Government Printing Office, 1989. 50. DuPont RL. Getting Tough on Gateway Drugs. A Guide for the Family. Washington, DC; American Psychiatric Press, 1984. 51. Schuckit MA. Ethanol induced changes in body sway in men at high alcoholism risk. Arch Gen Psychiatry 1985; 42:37579. 52. Schuckit MA, Rayses V. Ethanol ingestion: Differences in blood acetaldehyde concentrations in rehtives of alcoholics and controls. Science 1979; 20354-55. 53. Schucklt MA, Bernstein Lt. Sleep time and drinking history: A hypothesis. Am J Psychiatry 1981; 138528-30. 54. Scholossman S, Zellman G, Shavelson R, et al. Delinquency Prevention in South Chicago: A Fifty-Year Assessment of the

December

55.

56.

57.

58.

59.

60. 61.

62. 63. 64.

65.

66.

67.

1991

Prevention in South Chicago: A Fifty-Year Assessment of the Chicago Area Project. Sanka Monica, Rand, 1984. Hawkins < ID._ Lishner DM. Schooline v and delinauencv. In: Johnson EH, ed. Handbookon Crirneand Delinquency’Preve;llios, Westport, CT: Greenwood Press, 1987. flattjes RJ, Jones CL, eds. Etiology of Drug Abuse, Research Monograph No 56. DHHS Publication No. (ADM) 35-1335. Washington DC, US Government Printing Office, 1985. Gersick KE, Grady K, Sexton E, et al: Personality and sociodemographic factors in adolescent drug use. In: Lettieri DJ, Ludford JP, eds. Drug Abuse and the American _4dolescent, Research Monograph 38. DHEW Publication No. (ADM) Bl1166. Washington, DC, U.S. Government Printing Office, 1981. Murray DM, Perry CL. The prevention of adolescent drug abuse: Implications of etiological, developmental, behavioral and environmental models. In: Batties RI and lones CL, eds. Etiology of drug abuse: Implications for prevention. DHHS Publication No. 85-1335. Washington, DC, Supt. of Documents, US Government Printing Office, 1985. Mondanaro R. Medical services for drug dependent women. In: Beschner GM, Reed BG, Mondanaro J, eds. Treatment Services for Drug Dependent Women, vol. 1, NIDA Treatment Research Mc?nograph. Washington, DC, US Government Printing Office, 1981. Kokotailo I’, Adger H. Substance use by pregnant adolescents. Clin Perinatol 1991; 18125-38. Robins LN, Przybeck TR. Age of onset of drug use as a factor in drug and other disorders. In: Jones CL and Battjes RJ, eds. Etiology of drug abuse: Implications for prevention, DHHS Publication No. 85-1335. Washington, DC, Supt. of Documents, US Government Printing Office, 1985. Wright R, Jr, Watts TD. Alcohol and minority youth. J Drug Issues 1988; 181-6. Harper FD. Alcohol and black youth: An overview. J Drug Issues 1988; 187-14 Fraser MW. Reconsidering drug involvement among youth and young adults: I’mplications for targeted primary prevention. ] Social Social Welfare 1987; 1421-46. Johnston LD, OMalley PM, Bachman JG. Drug Use, Drinking and Smoking: National Survey Results from High School, College, and Young Adult Populaticms, 19?5-1988. RockviBe, MD, National Institute on Drug Abuse, 1989. Wolin SJ, Bennett LA, Noonan DL, et al: Disrupted family rituals: A factor in the intergenerational transmission of alcoholism. J Stud Alcohol 1980; 41:199-214. Gerstein DR, Harwood HS, eds. Treating Drug Problems, Committee for the Substance Abuse Coverage Study. Division of Health Care Studies, Institute of Medicine. Washington, DC, National Academy Press, 1990.

PROBLEMS OF ALCOHOL

AND OTHER DRUG ABUSE

613

68. Tarter RA. Evaluation and treatment of adolescent substance abuse: A decision tree method. Am J Drug Alcohol Abuse 1990; 16:l. 69. Rahdert ER, Grabowski J. Adolescent Drug Abuse: A.nalysis of Treatment Research. DHHS PTrblication No. (4zCiti) 881523. Washington, DC, US Government Printing Office, 1988 70. Bium RW. Adolescent substance abuse: Diagnostic and treatment issues. Pediatr Clin North Am 1987; 34.523. 71. Donovan JE, Jessor R, Jessor L. Problem Drinking in Adolescence and Young Adulthood. Publication. No. 184. Boulder, CO, Institute of Behavioral Science, University of Colorado, 1982. 72. Moore RD, Bone LR, Geller G, et al. Prevalence, detection, and treatment of alcoholism in hospitalized patients. JAMA 1989: 3:403-7. 73. MacDonald IX. Patterns of alcohol and drug use among adolescents. Pediatr Clin North Am 2 1987; 2:275-88. 74. MacDonald DI, Blume SB. Children of alcoholics. Am J Dis Child 1986; 2:7-17. 75. Kinney J, Price TRP, Bergen BJ. Impediments to alcohol coucation. J Stud Alcohol 1984; 45:453-59, 76. Duggan AK, Adger H, McDonald EM, et al. Detection of alcoholism in children and their families. Am J Dis Child 1991; 145613-7. 77. Bowen 0. The alcohol-abusing patient: A challenge to the profession. JAMA 1989; 15:2267-70. 78. AAP Committee on Adolescence: The role of the pediatrician in substance abuse counseling. Pediatrics 1983; 72:251-52. 79. Weschler H, Levine S, Idelson RK, et al. The physician’s role in health promotion: A survey of primary care practitioners. N Engl J Med 1983; 308:97-100. 80. Holden C. The neglected disease in medical education. Science 1985; 222:741-42. 81. Davis AK, Cotter F, Czechowicz D. Substance abuse units taught by four specialties in medical schools and residency programs. J Med Educ 1988; 63:739. 82. Adger A, McDonald EM, DeAngelis C. Assessment of substance abuse education. Pediatrics 1990; 86:555. 83. Adger H, McDonald EM, DeAngelis C. The Identification and Assessment of Alcohol and Drug Medica! Education Products/Approaches in Pediatrics: Final Report. DHHS Publication No. (ADMj 28i-8%d014. Rockville, ME, US Dept. of Health and Human Services, 1986. 84. Adger H, McDonald EM, DeAngeIis C. Ambulatory Pediatric Association/Pediatric Minimal Knowledge and Skills: The First Step in Developing a Curriculum in Alcohol and Other Drugs for Pediatricians. DHHS Publication No. (ADM) 28185-0014. Rockville, MD, US Dept. of Health and Human Services, 198%